Spock

I can only confirm what has been already stated especially doczilla's approach with know it all family members! I revert to six syllable words immediately. The research supporting lidocaine is old and not very good but it has worked its way into our practice and is used frequently. The rise in ICP is from two factors: muscle fasciculations and the laryngoscopy itself. You can get some fasciculations from etomidate but they are not has severe as with succinylcholine. A smooth and fast laryngoscopy decreases the ICP effect. Etomidate only intubation is not supported in the literature in terms of success rates although I routinely use only etomidate for intubating in the ICU or on the floor and have good success. The only time I use succinylcholine outside of the operating room is in the trauma bay because I figure I will only get one shot at securing the airway. Pennsylvania just added etomidate statewide and we are uncertain how it will work out. Time will tell. You must have a good backup airway plan and equipment before you should attempt any form of RSI or SAI. Planning to fail may sound negative but it is safe. Evaluation of the airway to recognize the potential difficult airway is important. The Malampatti scale is an old method and not very accurate. You frequently can't get a very sick patient to cooperate enough to actually perform it properly. Instead, look for decreased mouth opening, protruding upper teeth and receding chin for a more accurate evaluation. If the nose, lips and chin do not form a straight line you have a difficult airway and you may want to think twice before putting somebody down for intubation. How do figure out what is a straight line? Place a pen or pencil on the tip of the nose and see if the lips and chin touch the pen or pencil. Prehospital I have had good success with versed and fentanyl. Usually 4mg and 100mcg is more than enough to intubate. Versed alone does not work as well unless you give a large dose in which case you will crash the BP. Not a good option. If you want to pretreat with something other than lidocaine I would suggest fentanyl because it like etomidate does not have a great deal of hemodynamic effect although if you give a lot of either you will see the BP drop. Short half life of both makes this drop in BP transient. Live long and prosper. Spock

AZCEP--My post came one minute after yours so I did not read it until mine was posted. I couldn't agree with you more! Live long and propser. Spock

Good topic although some might be getting a little off track. I would suspect an SAH even though the headache went away until a CT scan either confirms or denies an SAH. The red herring is the nose bleed. I have never heard of epistaxis associated with SAH although anything is possible. I also believe lowering the BP out of hospital is rarely indicated. NTG is the worst choice because you have to give it frequently and the rebound effect can be worse. I administer anesthesia frequently in our neurointerventional radiology suite and I routinely run a neosynephrine gtt to keep the BP high. Sometimes in the 200 SBP range. IF we need to lower the BP we use beta blockers until the cardene is ready. Cardene is a great drug. I believe the original question concerned transport status. Lights and siren saves very little time and since you were only 10 minutes from the hospital I see no reason to "red ball it." L&S might only make the BP worse especially if you have a wild driver. Certainly the hospital needs to know they have a hypertensive patient coming in as soon as possible. Did you get any follow up? Live long and prosper. Spock

I've been an ACLS instructor for 17 years and I have to agree with everybody. AHA was worried about getting sued because people might not pass the class and lose their jobs. Never mind that they just didn't study or read the book. I do think pretests can help if used properly. It gives the student motivation to study if they have to submit the pretest before the class and pass it. Live long and prosper. Spock

This is certainly a good topic. I've given anesthesia for stimulator placement to treat Parkinson's. The cases were interesting but also difficult because you have to sedate the patient while the neurosurgeon drills a hole in the skull but then have them awake for lead placement and testing. Challenging to say the least. I agree that the best prehospital treatment is transport quickly to the hospital that implanted the device unless that was to far away. Supportive care would seem the best option because you can't be sure if the issue is device failure/malfunction or a neuroreceptor issue. You just don't have enough information as a medic. The drug abuse issue may be a red herring but I would not be fooled by a proud look of being clean. When I worked as an athletic trainer in the NFL we brought in a college player for an interview prior to possibly signing him as a free agent. He had a history of drug abuse and had actually served time in prison. Yeah, I told the coach he was crazy for considering him but we had a losing team the year before. Anyway, we asked the player for a urine sample for a drug test. He gave me the specimen cup and with a sincere look on his face said "This is some clean stuff." Ok, not the exact words but you get my drift. The lab called me the next day and the tech said he had never seen a higher level of cocaine in a sample and asked if the specimen came from an unconscious person. Needless to say we didn't sign him and I never let the coach forget it. Live long and prosper. Spock

I think the RSA has some merit. If you think the intubation will be difficult why not just punt to an alternate airway? Our new Pennsylvania state protocols always list ETI or alternative airway device (combitube or King LT) on the same line. It is worth considering. I'm not sure what a "non-visualized airway" is unless you mean putting the tube in the trachea without ever seeing the vocal cords. And yes, this gas passer has done it many times. Sometimes out of necessity and other times just to make it a challenge. Warning! I have gas and I know how to use it! Live long and prosper. Spock

I agree that you can't prepare to intubate while ventilating. EMT's should be familiar with the intubation process in order to be able to efficiently assist the medic during the procedure if needed. Intubating while compressions are in progress is difficult but not impossible. In order to minimize the interruptions in compressions (which we know is bad) I tell people to get their equipment ready and put the laryngoscope in the mouth just before a pause is scheduled. That way you can visualize the cords bouncing around and be ready to pass the tube when compressions stop. Some will argue that the primary airway in an arrest should be an alternative airway device (King LT, Combitube or LMA) instead of intubation because any of the alternatives can be placed during compressions. I can see both sides to the argument since this would remove most of the intubations done by paramedics which would decrease their skill. I do think we should stop using the term "rescue airway device" in favor of alternative airway device. Rescue airway has a negative connotation. The current issue of Prehospital Emergency Care has a case report of a helicopter crew that decided to intubate while in flight and chose to place an LMA after meds because they felt an intubation attempt would fail because of the cramped flight quarters and what looked like a difficult airway. They ventilated successfully with the LMA. Anthony This site has several forum topics covering many issues regarding intubation. Reading them is one way to expand your knowledge on the subject. There is also a text called Anyone Can Intubate by Christine Whitten. I have the third edition but I'm sure there is a newer edition. Live long and prosper. Spock

Looks like you've gotten a lot of good advice especially the part on furthering your education. If your hospital has a nursing program they will help you get through nursing school while you work in the ER in order to get another RN which every hospital needs. That is why the ER tech concept was originally developed. Most of the hospitals in our area use ER techs. I was a patient once for a kidney stone and the ER tech started my IV. He did a great job even though he was nervous because he knew me as a CRNA and a medic. My hospital lets the ER techs (they are paramedics) do any skill allowed as a medic except intubation. They restrict that because the ER has emergency medicine residents who need the tubes. Smaller hospitals may not have that restriction. It's great that you love your job so much and I would only suggest that you gain more experience before you start talking about nursing school. You may change your mind after six months. Most of the ER techs I know like working in the ER better than on the trucks because they have better pay, benefits and hours. They do give up autonomy but they feel it is a good trade off. Live long and prosper. Spock

Identifying the unrecognized CO poisoned patient is the purpose of the study we are participating in because flu like symptoms are the same. My service would never have come up with the cash for these devices so we are getting them through research. I did my own experiment on Saturday. Baseline Co level was 1% and only 2% after smoking a Fuente Churchill. If I would have had more time I would have smoked a second Fuente. Will have to try that some other weekend. Live long and prosper. Spock

VentMedic just gave you some awesome advice! I would say you might practice more on the mannequin with someone holding a stopwatch over you and placing the mannequin in the worst possible position. I have a research project underway where experienced paramedics have to intubate the mannequin every shift. So far there as been an improvement is success rate for those practicing on the mannequin. Don't get discouraged. Do get as much field experience as you possibly can. Good luck. Live long and prosper. Spock

I have to agree with chbare on this one. I've used the LMA in the OR for over ten years and the King for one year. The King was approved for use in the USA in 2005. I think the King is much better than the LMA for prehospital use for all of the reasons chbare stated. The combitube is ok but not my first choice for a rescue airway. Remember, I use the LMA and the King as primary airways for use in elective cases in the OR so I have a wealth of experience with both. I really don't see the LMA as a practical alternative in the prehospital arena. I think the King should be a BLS skill. Search this site for other forums addressing this issue. Live long and prosper. Spock

All I can say is croaker is right. RSI in ground services has proven effective but only if there is strict medical control and QA. Every article regarding successful RSI has these two items in common. Croaker--you da man! If you ever get to Pittsburgh let me know because I'll buy you a beer or four! Nifty My experience with people running propofol drips outside of anesthesia are they don't give enough of the drug. I routinely go to the ICU and see patients on propofol at 10 cc/hr and the nurse thinks this is a high dose. Wrong. While no two patients are the same and there are many variables, you need to run propofol at at least 50 mcg/kg/min in order to obtain sedation. If you give versed and fentanyl up front you may get away with less but not by much. Rarely does this occur outside of anesthesia. Either folks need to improve their understanding of the drug or they need to quit using it. In either case, use of propofol should be restricted to those who can intubate and have capnography in use. If the patient is already intubated then others may use the drug and let the blood pressure be your guide. If the SBP is > 100 you aren't giving enough! Just kidding but you get my point. Live long and prosper. Spock

I'm not up on wound care so I can't help much. We do use betadine to clean the site prior to surgery. The scrub is now something called triseptin (SP?). It is waterless and does not require a brush. The old scrub brush with phisohex prove to increase the contamination risk because of the abrasive effect on the skin. Triseptin is a liquid which is applied and rubbed in until dry. I think it is mostly alcohol because it burns like hell. We irrigate wounds with saline which sometimes has ancef added to it. A pulse lavage is used which applies the saline under pressure and 2-3 liters is usually used. Live long and prosper. Spock

OK, neither propofol nor etomidate have analgesic properties. Both are short acting and would not be suitable for sedation beyond about 10 minutes. Repeat doses of etomidate have been associated with adrenal suppression which may result in severe hypotension. In fact, this adrenal suppression has been reported with single doses. If this occurs hydrocortisone must be administered in order to reverse the hypotension. Propofol is usually restricted in the hospital for sedation of intubated ICU patients. Use for non-intubated patients is usually restricted to anesthesia personnel. Our ER docs are pushing my department to allow them to use propofol for sedation. Our chairman is forcing them to get capnography before he will authorize propofol. It will be interesting. Paramedics do not have the education nor experience to administer anesthesia. That is why Rid is absolutely correct in pointing out RSI in the prehospital realm is rapid sequence intubation and not induction. Live long and prosper. Spock

The RAD-57 is indeed outside the scope of practice for PA medics. Not sure why but then there are many things PA does that make no sense. We are going to get 5 units as part of a research project once 90% of our staff completes the training. We are going to use it on all patients in order to develop a data base. There are several services participating in the study. Normal values are important. Non-smokers should have readings <5% while smokers should be <10%. The device has a plus/minus factor of 3%. I have read anecdotal reports which question the accuracy of the RAD-57 and when we had it in for training all of the smokers had readings <5%. When we get the units I fully intend to get a base line reading on myself and then light up a big cigar to see if the number goes up! Don't forget that correlating the CO level in the field with carboxyhemoglobin levels in the hospital are greatly affected by the transport time with the patient on high flow oxygen. If transport takes a few minutes there may not be much of a difference. If transport is much longer the difference would be significant because oxygen is the treatment for CO. Good luck. If you can get grant funding for the unit it might make sense as long as your service does not have greater needs. As always, treat the patient and not the monitor. Live long and prosper. Spock

The cross over reaction between ancef and PCN exists but is not very common. I think the rate is around 1-2%. Unless the allergy to PCN is anaphylaxis or uticaria we give them ancef. Also, the orthopedic surgeons call ancef orthocillin. Just a joke. Not all patients in the OR get ABO prophylaxis. Some surgeons do not give it for lap chole's as an example. Single doses of ABO's have been know to cause megacolon which can be fatal. The issue of ABO's for remote areas is complex and I think the time involved is critical. The longer it takes to reach definitive care the greater the need for ABO coverage. The surgeon was a jerk not to recognize it wasn't your fault the patient didn't receive ABO's. Live long and prosper. Spock

There is no question in my mind that Dr. Wang has a "hidden agenda" which brings into question his objectivity as a researcher. Nevertheless his work is out there and nobody is refuting it. Medics must begin to develop their own body of research if they are to survive in this "evidence based medicine" climate. I'm not sure I would compare placing an NG with intubation. Nobody ever died from a failed NG placement. Can't intubate/can't ventilate is fatal. Live long and prosper. Spock

I knew I would forget something. Chbare mentioned a new alpha-2 agonist. It is called dexmedetomidine. It has a short half life (1.5 hours) and rapid onset of action (<5 min) with peak effect in 15 minutes. We just added it to our formulary and I have not used it as of yet. It's use would be for sedation because it has little to no effect on respiration. It is supposed to sharply decrease endogenous catecholamines which would drop the BP and heart rate. I'll try to get back to you all after I've used it a few times. Live long and prosper. Spock

Thanks for clearing that up AZCEP. Suxs as an induction agent is a common misconception. Many people also think vecuronium or rocuronium are induction agents when they are not. Paralyzed but awake is a very bad thing. Pennsylvania just added etomidate and a sedation assisted intubation (SAI) protocol statewide. Each region has to approve its use and then the local medical director has to credential the paramedics under his/her control. The QA process is three level: local, regional and state. I'm not sure how this will work out but I'm on the committee setting up the process for my region. I have mixed emotions about it. Some medics I would trust but most I would not. There is a great deal of research out there on this topic and I can't cite all of it just off the top of my head but a few things come to mind some of which have already been pointed out. Versed will drop the blood pressure in any dosage. Simple fact supported by literature and experience. Etomidate will cause less of a BP drop although at higher dosages it will drop the BP just as much as versed. Anyone can learn to intubate but to be proficient you must do the skill on a regular basis. Medics don't. Wang reported almost 40% of PA medics intubated nobody in one year and the average was 2. If you were a medical director would you give RSI or SAI to medics with 2 tubes in a year? Think about it. The jury is still out on whether or not SAI improves intubation success rates. Some literature says it does but most say it does not. I've tubed people in the ambulance using only versed and fentanyl and I am not fond of the procedure. I got the tubes only because I'm experienced since the conditions were suboptimal at best. Rescue airways are crucial for any intubation protocol. I like the King LT but the combitube or LMA are also reasonable. The number of prehospital intubations will decrease as more services start to use CPAP. This happens in the ED and the ICU already. In five years most medics won't be intubating. Just my opinion. Good topic and dialogue. Live long and prosper. Spock

An endo tube at 25 cm is probably in the right mainstem no matter how tall. At 74 inches I would not have the tube at anything less than 21 cm. The pneumothorax might have been caused by pressure against a closed glottic opening. He held his breath, pulled the trigger and the shock wave traveled downwards against the thorax. With the glottic opening closed there was no way to release the pressure other than a pneumothorax. If that doesn't make any sense please feel free to tear it apart because it is the only thing I can think of. Live long and prosper. Spock

Pennsylvania does not require an associates degree. We do have permanent certification. Live long and prosper. Spock

Trendelenburg position will also decrease functional residual capacity in the lungs which will increase dyspnea in a shock patient. This is from the abdominal contents pushing up on the diaphragm. That said, we often put the patient into t-burg for central line placement. Also, when we prep the patient for a CABG, both legs are elevated to at least 60 degrees in order to prep the posterior legs. At this point I watch the SBP increase by at least 20 mmHg. Live long and prosper. Spock

It seems to me this doctor has things backwards. He is the one with MD behind his name so he should produce research that says high flow oxygen is detrimental and have the protocol changed. High flow oxygen is clearly not indicated for every patient and judgement should be utilized. I've long felt that the difference in FiO2 between 10L/min and 15L/min is not clinically significant but does empty the tank one third faster. Live long and prosper. Spock

Exactly right whit. If you don't do the easy ones you won't be able to do the difficult ones. Quality comes with quantity. You guys are right about the PASG and EOA's but if medics don't stand up for themselves they may lose ETI. Alternative airway devices are not as good as ETI but in the hands of the inexperienced they are more than adequate. Look at the trend from the AHA with ACLS and PALS. Clearly it is away from ETI for all but the most experienced (undefined term) and towards alternative airways. AHA doesn't call the shots with EMS but they do have a powerful message. Live long and prosper. Spock

Tough subject that has received a lot of attention in the past few years. AZCEP and Rid have a good handle on this and it is nearly impossible to compare one country against another. I've been a CRNA for ten years and a paramedic for 18 so I've been on both sides of the equation. Just some thoughts. CCRN's do not intubate but CRNA's do. I did almost 600 intubations during my anesthesia training over 2 years. I work for an anesthesiology group and I guarantee you I do more tubes than the doctors. That's one part of my job. My hospital is one of the few in our region that still lets medic students and flight crews in the OR for tubes. The doctors I work for feel that it is part of their jobs to teach and more than one has said that if they ever need intubated they want a well trained paramedic to do it so they are willing to take the risk. The research is varied and some is suboptimal but the trend is clearly against paramedics intubating. Where this will all end up is unknown but if medics want to continue intubating they have to do a better job than they are currently. I started a research study with my service where medics are required to intubate the mannequin every shift. I'm trying to show that mannequin practice will improve first time success rate (the average first time success rate across the country seems to be in the 65-70% range.) Unfortunately I'm having a hard time getting people to do the mannequin time because of apathy. They just don't seem to give a damn. They all brag about their tubes but when I look at the trip sheets it is clear that they aren't doing a good job. Yes that is just my service and may not apply to others. A neighboring service had a medical director set up OR time for his medics on a voluntary basis and not one medic ever went into the OR. Wang reported that almost 40% of Pennsylvania medics had ZERO intubations in one year. The average was 2. The study had some flaws but it is still out there. ETI is a high risk procedure that requires practice plain and simple. Most medic intubations are in the cardiac arrest population. Compressions and defib are the only interventions that have been proven to make a difference in the cardiac arrest. Where is this going? I don't know and neither does anybody else. My feeling is that medics will not be allowed to intubate within five years and ETI will be replaced with either the King, LMA or combitube. I feel the King is superior but it hasn't been on the market in the US long enough to gain acceptance. That will come with time because as I have said before I think the King is a better airway than the others. Only time will tell. Medics are going to have to fight to keep the skills they currently have and research is the only way to succeed. I'm still looking for the study showing how many intubations ER doctors do in a year. I suspect that MD's in teaching hospitals don't do more tubes than medics because they always have a resident around who wants and needs the tubes. Someone asked Dr. Wang how many tubes he did in a year and he wouldn't answer the question. What does that say? Live long and prosper. Spock