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

[policemedic]

Red Flag 1 - Excellent idea in the other thread.

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

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:

 

[x SF med]

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.

 

[policemedic]

Efficiency is never out of fashion.

 

[pardus]

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

Ow, fuck that lol

 

[surgicalcric]

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...

 

[pardus]

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...

 

[medicchick]

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.

 

[Muppet]

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.

 

[pardus]

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.

 

[Muppet]

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.

 

[TLDR20]

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.

 

[surgicalcric]

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

 

[Muppet]

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.

 

[pardus]

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.

 

[medicchick]

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

 

[policemedic]

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.

 

[policemedic]

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.

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?

 

[policemedic]

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?

 

[policemedic]

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.

 

[policemedic]

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.