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

[Dropkickmedic]

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.

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.

 

[Devildoc]

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.