# Of Airway Management, Intubation, Crics, and tubes large and small



## policemedic (Jan 10, 2012)

Red Flag 1 - Excellent idea in the other thread.  

Since the topic is wide open, I'll start with this.



pardus said:


> As a medic we just use lube for nasal intubation. Not a pleasant feeling but not terrible either.
> 
> FYI, Army Medics no longer have oral intubation as an option during TC3. Nasal then a cric.


 
For clarity's sake, when I refer to nasal intubation I'm referring to the use of an endotracheal tube.  I've had the dubious pleasure of allowing my paramedic students to insert nasopharyngeal airways, NG/OG tubes, and nasal ET tubes in me.  I drew the line at being a test dummy for EJs .

As a result, it is my strong belief that where these procedures are concerned lube and anesthetics are your friends, but technique is everything.  This is true especially when coaching a panicky patient through a nasal intubation.  

I agree with the TC3 recommendations.  Dedicating the time and personnel to perform orotracheal intubation in the first phases of TC3 is bad mojo.  

In fact, I would argue that the training required to even become safe when managing the airway with an ET tube (A&P, cardiac/waveform ETCO2  monitoring [when available], video training, pharmacology, manikin training, simulator/cadaver/OR/ED tubes etc.) let alone skilled at the procedure requires such a commitment of resources and time that it should not be part of the average (and I stress _average_) 68W's toolkit.  Laryngoscopy is not a benign procedure.  The Big Army medic has other skills to manage the airway that are easier to develop and maintain clinical competency with.  Training should be directed at sustaining those critical skills e.g. cut big or go home.

Now regarding blind awake nasal intubations, I used to do quite a few.  The typical pt presented with an acute exacerbation of CHF.  Nowadays, not so much.  Other treatment modalities, particularly where CHF is concerned, are available that render nasal intubation a very low-frequency procedure.  I still have a BAAM on my stethoscope, but some newer medics will occasionally ask why.

This should stir up enough controversy for now.  :nerd:


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## x SF med (Jan 11, 2012)

although way out of fashion... in a bad place, when you need to secure an airway for rough transport.... a well placed, taped in J-tube does work to keep a patent airway for bag breathing.


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## policemedic (Jan 11, 2012)

Efficiency is never out of fashion.


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## pardus (Jan 11, 2012)

policemedic said:


> For clarity's sake, when I refer to nasal intubation I'm referring to the use of an endotracheal tube.


 
Ow, fuck that lol


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## surgicalcric (Jan 11, 2012)

Retrograde intubation... (ET tube, 14ga cath, and an inducer wire from a central line is all thats needed...well that and forceps which I have pleny of in my bag) and can be performed much faster than laryngoscopic intubation and its far safer than crics too.  

Both laryngoscopy (controlled setting) and crics  (massive facial trauma, occluded airway superior to the cords, etc...) have their place(s) but I am going with the RI first.

But thats just me...


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## pardus (Jan 11, 2012)

surgicalcric said:


> Retrograde intubation... (ET tube, 14ga cath, and an inducer wire from a central line is all thats needed...well that and forceps which I have pleny of in my bag) and can be performed much faster than laryngoscopic intubation and its far safer than crics too.
> 
> Both laryngoscopy (controlled setting) and crics (massive facial trauma, occluded airway superior to the cords, etc...) have their place(s) but I am going with the RI first.
> 
> But thats just me...


 
Well I just learned something new...


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## medicchick (Jan 11, 2012)

We were taught it, but I've only done one outside class.  My mentor did tell me that if you can get the pt to cough it goes in easier.  For the most part, they were either bad enough to need a regular tube, ride on a helo with them doing a cric (not allowed in Kent County as Paramedics), or stable enough to last for hauling ass to the ER.  Nasal spray first, lube the tube, then go.


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## Muppet (Jan 11, 2012)

I used to do tons of nasal tubes (intubation),( Police medic and I trained in the same city fire rescue) but with the advent of CPAP, that skill has decreased. I also carry a BAAM on my ears. Lets talk about R.S.I. / M.E.I.: In the state of P.A.... We are skilled to use etomidate to snow somebody for intubation BUT what do you guys and gals think about JUST etomidate? I contend that giving a bullshit S.O.P. for airway mangement w/o allowing paralytics is stupid. I.E.: 20 y/o male, motor cycle M.V.C. with massive head trauma / unconscious, trismus and combative. S.O.P.'s allow us to (a): Sedate with versed and (b): facilate intubation with etomidate, not together though. I say that in the presence of head injury should we not be allowed to use the whole R.S.I. S.O.P., you know with paralytics (which will never happen in the state, sorry.. commonwealth of P.A.). Where am I going with this? PARALYTICS is the way to go and not giving a b.s. S.O.P. just to satisfy the masses is dangerous and retarded.

In response to Nasal intubation... There is still a place for it in the civ. world / I just did one a few weeks back on a tricyclic overdose that was unconscious and it was easy. My trick: Place the Etco2 detector AND the BAAM valve on the tube prior to inserting and watch the waveform / listen for the wistle of the BAAM. Sweet stuff. I am turned on now.

Now: I firmly believe in the usage of a secondary airway, such as the KING or Combitibe (we use the King) in my area for cardiac arrest so you don't interupt compressions. What say you. Let the controversy regarding intubation in cardiac arrest begin. 

F.M.


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## pardus (Jan 11, 2012)

Firemedic said:


> Now: I firmly believe in the usage of a secondary airway, such as the KING or Combitibe (we use the King) in my area for cardiac arrest so you don't interupt compressions. What say you. Let the controversy regarding intubation in cardiac arrest begin.
> 
> F.M.


 
Army says King and Combi are a no go now.


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## Muppet (Jan 11, 2012)

pardus said:


> Army says King and Combi are a no go now.


 

Really? When. I imagine duging C.U.F. it obviously is a no go but what about T.F.C. / CASEVAC?

F.M.


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## TLDR20 (Jan 11, 2012)

I think the king LT is a great piece of kit. It is what I had in my bag and is what I have used in a real scenario.


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## surgicalcric (Jan 11, 2012)

As for nasal intubations, not a big fan personally. 

Not a fan of Etomidate by itself either.  Thats a 1/2 assed means of RSI/MEI.  Whoever made the decision to only let you guys use Etomidate should not be allowed to practice medicine.

Crip


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## Muppet (Jan 11, 2012)

surgicalcric said:


> As for nasal intubations, not a big fan personally.
> 
> Not a fan of Etomidate by itself either. Thats a 1/2 assed means of RSI/MEI. Whoever made the decision to only let you guys use Etomidate should not be allowed to practice medicine.
> 
> Crip


 
You and my medical director think the same but it is the state med. director that with "stakeholders" made this retarded S.O.P. It used to be versed only and changed to etomidate only. Don't get me started. LOL.

F.M.


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## pardus (Jan 11, 2012)

Firemedic said:


> Really? When. I imagine duging C.U.F. it obviously is a no go but what about T.F.C. / CASEVAC?
> 
> F.M.


 
NPA and then a Cric, that's it for medics now. Can't speak for flight medics and others above me.


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## medicchick (Jan 11, 2012)

Never was able to do RSI while I was in Michigan, it was a NOGO so we didn't even have the drugs for it. Carried Combitubes, never used one though. If we were doing CPR, we tubed first. This was also the days of Lifepack 10's though so that dates me a bit...lol


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## policemedic (Jan 11, 2012)

pardus said:


> Army says King and Combi are a no go now.


 
I'm betting this has a lot to do with the Army not being willing to invest in training time and realizing that their update and sustainment programs are the educational equivalent of pissing in the wind.

If MOSQ requires achieving National Registry as an EMT-B, then allow the Soldiers to perform as such.


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## policemedic (Jan 11, 2012)

Firemedic said:


> BUT what do you guys and gals think about JUST etomidate? I contend that giving a bullshit S.O.P. for airway mangement w/o allowing paralytics is stupid.


 
You know what I think 

It's absolutely unconscionable that I was required to teach RSI when I was making paramedics, but the only place they were allowed to execute the procedure was the OR/ED (primarily OR).

With that said, I think maintaining competency in rapid sequence induction requires an amount of skill sustainment that is incompatible with many EMS systems, particularly mine.  I don't think there is enough opportunity to drop tubes, maintain competency, etc. in a large urban EMS system.  In selected circumstances, I have faith it can be done safely and with good outcomes.  But the key is selecting the right medics, and being committed to continuing skill maintenance.



Firemedic said:


> What say you. Let the controversy regarding intubation in cardiac arrest begin.
> Fucker.
> 
> I think that airway management doesn't necessarily equate to intubation, and that (medical) cardiac arrest is usually due to several factors not related to the airway.  Manage the airway, sure, but work the primary problem-why did the pt arrest in the first place and can we reverse it?


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## policemedic (Jan 11, 2012)

medicchick said:


> Never was able to do RSI while I was in Michigan, it was a NOGO so we didn't even have the drugs for it. Carried Combitubes, never used one though. If we were doing CPR, we tubed first. This was also the days of Lifepack 10's though so that dates me a bit...lol


 
I trained on LP10s, and used them for awhile.  Hell, I remember humping a LP11.  You calling me old?


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## policemedic (Jan 11, 2012)

surgicalcric said:


> As for nasal intubations, not a big fan personally.
> 
> Not a fan of Etomidate by itself either. Thats a 1/2 assed means of RSI/MEI. Whoever made the decision to only let you guys use Etomidate should not be allowed to practice medicine.
> 
> Crip


 
The decisions made by the Commonwealth's medical director are the result of his lack of faith in volunteer services in the western part of the state.  This results in a lowest common denominator approach to the practice of emergency medicine, and it's why the statewide paramedic protocols are such a dismal failure.  But I digress.  Thank God I work with a doctor who has his head screwed on straight.


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## policemedic (Jan 11, 2012)

surgicalcric said:


> Retrograde intubation... (ET tube, 14ga cath, and an inducer wire from a central line is all thats needed...well that and forceps which I have pleny of in my bag) and can be performed much faster than laryngoscopic intubation and its far safer than crics too.
> 
> Both laryngoscopy (controlled setting) and crics (massive facial trauma, occluded airway superior to the cords, etc...) have their place(s) but I am going with the RI first.
> 
> But thats just me...


 
I agree completely. I always thought the retrograde technique was an elegant method, and it was easy to teach to boot. Easier, in fact, than teaching some people proper laryngoscopy technique.

Speaking of laryngoscopy, I believe Dr. Richard Levitan and his AirwayCam revolutionized the instruction of novice incubators.  I'm very much looking forward to testing out the CricKey device he co-developed with LTC Bob Mabry when it becomes available.


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## surgicalcric (Jan 11, 2012)

policemedic said:


> I trained on LP10s, and used them for awhile. Hell, I remember humping a LP11. You calling me old?


 
Speaking of old, I learned on a LP5 in Paramedic school.  ;)


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## Red Flag 1 (Jan 11, 2012)

My $.02

RF 1


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## medicchick (Jan 11, 2012)

policemedic said:


> I trained on LP10s, and used them for awhile. Hell, I remember humping a LP11. You calling me old?


 
Maybe

Although, I'm only 30 and that's what I learned on and used as a student...ah the good old days, has it really been 10 years?


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## pardus (Jan 11, 2012)

policemedic said:


> .If MOSQ requires achieving National Registry as an EMT-B,


 
I heard a rumor that might be dropped soon.
I think having a B is a waste of time, we should be civi qual'd to an Intermediate IMO.


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## policemedic (Jan 12, 2012)

pardus said:


> I heard a rumor that might be dropped soon.
> I think having a B is a waste of time, we should be civi qual'd to an Intermediate IMO.


 
We could fill an entire thread on 68W training.  I'm sure there are plenty of strong opinions on that topic.


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## policemedic (Jan 12, 2012)

Red Flag 1 said:


> ... and the cuff has been tested first. There is nothing more frustrating than struggling an ETT in place only to find the cuff has a leak.


 
Excellent point, and where I've seen a lot of people go wrong (and not just with airway management).  Professionals test their equipment before they use it.  Yes, it takes time (hence, why I love to say RSI is not rapid at all), but it's absolutely necessary to prepare and test your equipment.  I can't tell you how many times I've heard someone curse when they found their laryngoscope bulb was dead (I'm dating myself, I know) or loose, or the 'scope simply needed new batteries.  



Red Flag 1 said:


> ... on inspiration only. As you near the vocal cords, the inspirations will sound louder, and stronger as the ETT advances. If there is a cough, advance a few millimeters more, then stop and inflate the ETT cuff, you are in the trachea.


 
"Ok, we're almost done.  Take a big, deep breath..." :nerd:


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## Muppet (Jan 12, 2012)

policemedic said:


> I trained on LP10s, and used them for awhile. Hell, I remember humping a LP11. You calling me old?


 
Hey D. You talking about the LP-11 that we carried @ good ole Medic-96?

F.M.


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## Muppet (Jan 12, 2012)

policemedic said:


> The decisions made by the Commonwealth's medical director are the result of his lack of faith in volunteer services in the western part of the state. This results in a lowest common denominator approach to the practice of emergency medicine, and it's why the statewide paramedic protocols are such a dismal failure. But I digress. Thank God I work with a doctor who has his head screwed on straight.


 
I don;t neccessarly think the protocols are that bad but they could be a little more aggressive, such as not having to call for steriods for allergic reactions but have them in standing orders for resp. emergencies. LOL. Thanks god I work in a county that is o.k. and I have a medicla director that is AGGRESSIVE!

F.M.


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## Muppet (Jan 12, 2012)

surgicalcric said:


> Speaking of old, I learned on a LP5 in Paramedic school. ;)


 

Damn, now thats old.

F.M.


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## policemedic (Jan 12, 2012)

Firemedic said:


> Hey D. You talking about the LP-11 that we carried @ good ole Medic-96?
> 
> F.M.


 
Yep.  I sooooo much prefer LP12s or the Phillips over that beast.


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## Muppet (Jan 12, 2012)

policemedic said:


> Yep. I sooooo much prefer LP12s or the Phillips over that beast.


 
I am not crazy about the LP-12. I like the Philips but I have been using that for a while so I am used to it. Hell, even Medic-168 went to Philips and we are being in-serviced on them now / I am exempt of course.

F.M.


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## amlove21 (Jan 15, 2012)

I'm a little late here, so I will just throw some quick hits for my personal choices for airway. 

- Huge fan of the KING LTD. I carry them in my bag. Not my first choice, but great in MASCAS or as a second to last ditch.
- I am not afraid to cric at all, although I do agree with all of those that cite the inherent complications associated with the procedure. TCCC moves you in that direction (for advanced practitioners) pretty quickly. Using lidocaine to numb the area of an awake pt (needle through the cric membrane, big spray and cough for the PT) seems to work well. I've never done it, but I did stay at a Holiday Inn Express once. 
- I did chuckle at (I think Policemedics) "I like the King for not interrupting compressions"- isnt that what being REALLY good at intubating is supposed to alleviate? Kidding! But seriously, you should be good at intubating people or just not do it. You get one, maybe two shots at a viable patient, so you better hit it. 
- The RSI/PAI (pharmacologically assisted intubation) question is pretty intriguing. For instance, I dont carry Etomidate or any paralytics, so we have had lots of conversations about a good way to put someone down, manage their airway, and keep them down with the stuff we have. One of the answers? Preload pt with 2-4 mg of Versed, mix Ketamine, fentanyl, and propofol in a 500cc bag of saline. Run wide open until pt is down, secure airway, titrate drip of happy juice to "not awake". I wanna stress this is just a conversation amongst the operators and docs/IDMT's, this isn't part of our protocol as it stands. But our medical control is pretty lenient on what we can do, and we bring wacky ideas to them now and again and get it approved to try out. If we cant carry propofol (mostly due to getting our hands on it or how it has to be stored), you can do this with a little more pre-load of ketamine. Everything else remains the same. 

Anybody smarter than me (read:everyone) feel free to weigh in on this.


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## HoosierAnnie (Jan 15, 2012)

"Mercy buttercups" Guys. This nurse has thoroughly enjoyed reading and learning from this discussion.


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## Manolito (Jan 15, 2012)

Each county EMS has a procedure for EMT-B and running ambulance in the Bay Area of California is a tough job. You have to petition each county with your qualifications and then get a photo id to work in each county. This made things hard because out on the Research vessel you were able to and expected to do what the Dr. on the radio directed. Then when working the counties mostly to recert you had to back up a mile on what you could do. Being nationally certified is a big help when in this situation all the counties I worked for accepted this better than individual fire or county certification. hell we would pick up hospice patients with drips of happy juice and couldn't proceed to the next county to their hospital of record because that county did not allow B's to tranports Iv patients. Funny world out there and some great Dr's willing to share what they know. Others not so willing.
one county you could remove objets penetrating the cheek and in others stabilize the penetrating object and transport. Interesting when it is a 6 ton pneumatic press.
This was in the 90's so I don't know if it is that way in other parts of the country.
I was working an ER and had a EMT bring in a patient and he was bagging the hell out of him and you could watch the stomach rise and fall on each squeeze of the bag. Might have missed it sparky.
Infants and toddlers are the worst nothing fits that I carried. Finally a Dr. set me up a small box for children things got easier.
I sure don't miss it to be honest. The only thing bad about retirement is you have to be old to retire.
Bill


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## policemedic (Jan 15, 2012)

amlove21 said:


> I'm a little late here, so I will just throw some quick hits for my personal choices for airway.
> 
> - Huge fan of the KING LTD. I carry them in my bag. Not my first choice, but great in MASCAS or as a second to last ditch.


 
Agreed. I have a strong opinion that 2nd and 3rd tier backup airways are a good thing. I never want to be in a difficult airway situation without multiple options.



amlove21 said:


> - I am not afraid to cric at all, although I do agree with all of those that cite the inherent complications associated with the procedure. TCCC moves you in that direction (for advanced practitioners) pretty quickly. Using lidocaine to numb the area of an awake pt (needle through the cric membrane, big spray and cough for the PT) seems to work well. I've never done it, but I did stay at a Holiday Inn Express once.


 
Lido is your friend. I think eliminating pain prior to a procedure (blocks, etc.) is a good thing. Of course, when you need that tube in _yesterday_, there's no time and you just have to cut big or go home.



amlove21 said:


> - I did chuckle at (I think Policemedics) "I like the King for not interrupting compressions"- isnt that what being REALLY good at intubating is supposed to alleviate? Kidding! But seriously, you should be good at intubating people or just not do it. You get one, maybe two shots at a viable patient, so you better hit it.


 
Nope, that was my brother from another mother. I completely agree with you about being skilled, and getting it done the first time. Anyone who has intubation in their toolbag should also be an expert at assessing the pt's airway and evaluating the chances that it will be a difficult airway. This should be done with every pt, every time. If the decision is made to orally intubate someone with a predicted difficult airway, then knowing that beforehand allows you to lay out your "oh shit" 2nd/3rd tier devices. And sometimes, the best decision is to choose another method/device.



amlove21 said:


> - The RSI/PAI (pharmacologically assisted intubation) question is pretty intriguing. For instance, I dont carry Etomidate or any paralytics, so we have had lots of conversations about a good way to put someone down, manage their airway, and keep them down with the stuff we have. One of the answers? Preload pt with 2-4 mg of Versed, mix Ketamine, fentanyl, and propofol in a 500cc bag of saline. Run wide open until pt is down, secure airway, titrate drip of happy juice to "not awake". I wanna stress this is just a conversation amongst the operators and docs/IDMT's, this isn't part of our protocol as it stands. But our medical control is pretty lenient on what we can do, and we bring wacky ideas to them now and again and get it approved to try out. If we cant carry propofol (mostly due to getting our hands on it or how it has to be stored), you can do this with a little more pre-load of ketamine. Everything else remains the same.


 
We're in sort of the same situation. Without proper drugs, we (PA medics) sometimes find ourselves in difficult situations. With that said, I'm fully aware of the difficulty associated with implementing RSI in an EMS system.


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## surgicalcric (Jan 15, 2012)

policemedic said:


> ...We're in sort of the same situation. Without proper drugs, we (PA medics) sometimes find ourselves in difficult situations. With that said, I'm fully aware of the difficulty associated with implementing RSI in an EMS system.


 
Move to Greenville, SC. We have had RSI as part of our standing orders since about 2002 and crics for nearly that long...    Seem to remember thrombolytics being started about 97-98 time frame too...


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## Muppet (Jan 15, 2012)

surgicalcric said:


> Move to Greenville, SC. We have had RSI as part of our standing orders since about 2002 and crics for nearly that long... Seem to remember thrombolytics being started about 97-98 time frame too...


 
I seem to remember a dude from Greenville, taking a IPIMBA course (bicycle course) @ my squad a few years back. He had his face in the magazine Jems regarding the type of truck you guys use (Wheeled Coach) I believe. Blond with a flat top haircut.

F.M.


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## policemedic (Jan 16, 2012)

surgicalcric said:


> Move to Greenville, SC. We have had RSI as part of our standing orders since about 2002 and crics for nearly that long... Seem to remember thrombolytics being started about 97-98 time frame too...


 
Must be nice. One more reason to move to the South!

Needle/surgical crics are no issue here, and haven't been for as long as I can remember (as long as you're not constantly doing them; that would ring a few bells). We can use any method we like to intubate, except retrograde (which is a shame). I do believe RSI should be available to paramedics, as long as there is a robust QA/QI program with an involved medical director.

Where lysing in the field is concerned, many squads, especially the volleys in Western PA, didn't want to buy 12-lead capable monitors until they were forced to by licensing requirements. Others simply weren't interested e.g. the Philadelphia Fire Department, and they're the largest EMS service in the Commonwealth. FM and I worked for the first service in our area to use 12-leads, and even there some medics opposed it despite the clear benefits. Additionally, there was much debate about transport times, medic vs. MD interpretation of the 12-lead, etc. With such a varied landscape of opinion, it's not surprising TNK or Retavase never ended up on the trucks.


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## policemedic (Jan 17, 2012)

amlove21 said:


> One of the answers? Preload pt with 2-4 mg of Versed, mix Ketamine, fentanyl, and propofol in a 500cc bag of saline. Run wide open until pt is down, secure airway, titrate drip of happy juice to "not awake". I wanna stress this is just a conversation amongst the operators and docs/IDMT's, this isn't part of our protocol as it stands. But our medical control is pretty lenient on what we can do, and we bring wacky ideas to them now and again and get it approved to try out. If we cant carry propofol (mostly due to getting our hands on it or how it has to be stored), you can do this with a little more pre-load of ketamine. Everything else remains the same.


 
Not that this has anything to do with airway, but I meant to mention this yesterday since you mentioned ketamine.  It's in the process of being approved and included into PHTLS protocols for pain management.


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## amlove21 (Jan 17, 2012)

policemedic said:


> Not that this has anything to do with airway, but I meant to mention this yesterday since you mentioned ketamine. It's in the process of being approved and included into PHTLS protocols for pain management.



New thread alert!


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## Dropkickmedic (Sep 22, 2020)

amlove21 said:


> I'm a little late here, so I will just throw some quick hits for my personal choices for airway.
> 
> - Huge fan of the KING LTD. I carry them in my bag. Not my first choice, but great in MASCAS or as a second to last ditch.
> - I am not afraid to cric at all, although I do agree with all of those that cite the inherent complications associated with the procedure. TCCC moves you in that direction (for advanced practitioners) pretty quickly. Using lidocaine to numb the area of an awake pt (needle through the cric membrane, big spray and cough for the PT) seems to work well. I've never done it, but I did stay at a Holiday Inn Express once.
> ...



In regards your RSI/PAI recommendation. After the pre-load of Versed the rest of the medications are still weight based correct? Ketamine at 1-2 mg/kg / Fentanyl at .002 to .02 mcg/kg; maintenance levels / Propofol at 6mg/kg upto 12mg/kg also maintenance levels. 

For the average troop of 100kg I would consider Ketamine 100mg / Fentanyl 2mg / Propofol 10mg. Equaling 120cc of medication introduced into the 500cc bag of NS at a rate of say .5mg/Kg/minute giving the medic basically at 5mg per minute dose from a 500ml bag over a 2 hour period would be 20 drops a minute. Does this sound right.


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## Devildoc (Sep 22, 2020)

Dropkickmedic said:


> In regards your RSI/PAI recommendation. After the pre-load of Versed the rest of the medications are still weight based correct? Ketamine at 1-2 mg/kg / Fentanyl at .002 to .02 mcg/kg; maintenance levels / Propofol at 6mg/kg upto 12mg/kg also maintenance levels.
> 
> For the average troop of 100kg I would consider Ketamine 100mg / Fentanyl 2mg / Propofol 10mg. Equaling 120cc of medication introduced into the 500cc bag of NS at a rate of say .5mg/Kg/minute giving the medic basically at 5mg per minute dose from a 500ml bag over a 2 hour period would be 20 drops a minute. Does this sound right.



You can't fart around with those drugs, you have to do it on a pump.  One pot hole in the ambulance, one down draft in a helicopter, your 20 drops a minute turns into either 5 or 200.

Also consider the effects of the fentanyl and propofol on blood pressure in balance with why inducing to intubate.


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