JEMS article regarding Medics and intubation

[mediccjh]

Trauma, TBI in particular is a small subset of patients requiring prehospital intubation. San Diego and Los Angeles have medics coming out of their ears, way too many providers and very little skill use. 2 tubes a year doesn't cut it. Don't know much about Baltimore other than it is run by an east coast fire department, and the Wang study in Pennsylvania looked at the entire state, no just a city like Pittsburgh (3rd service) and I don't believe it addressed RSI. The data out of the Pacific Northwest goes contrary to the data from the California fire services, and our data, although not yet published would suggest and improved outcome in the TBI population, as well as other, non trauma patients as well. I agree that as it stands today, not every medic should be performing intubation, but the answer lies in education and experience, not on removing a potentially life saving skill, in my opinion.

Wang can't address RSI in PA, because we don't have it.

[p3medic]

I've seen LMA's in the ED as a back up to failed intubation, never seen one used as the initial airway of choice (in the ED). I 100% agree we should prove what we do. The problem is, when someone like Wang publishes a study based on ETI success in the entire state of Pennsylvania you are not looking at individual systems but the entire state. I agree that across the board intubation success rates should be similar, but we all know they are not. Every system should start their own airway registry and collect data on every tube to prove we improve outcomes, or perhaps we don't. Either way, a medic in system A is not the same as a medic in system B despite what we would like to think. The National Airway registry looks at ED intubations across the U.S., we have an airway registry for our department modeled after it. If it takes a physician x # of intubations to learn the skill, and x # to stay proficient it should stand to reason it would take a similar experience for a paramedic to do the same. I think live OR intubations would be the best, however some of the newer simulators do a fair job of creating difficult intubation senarios. QA/QI is an absolute must.

[tniuqs]

This Aiway Registry is a good idea IMH estimation, but what about those forgotten few, the remote practtioner and those in hostile enviroments, most of those Medics have years of experiance ... and usually why they are hired in the first place.

But the # of ETI is rather low ... is there anyway of going back and checking the books ... I am talking way back like 25 years to prove reliability and experiance, honestly if the registry starts say in Jan of 2009 would those individuals be viewed in the same light as a 1st year Grad as that would not really be a fair comparison.

Wang can't address RSI in PA, because we don't have it.

Wang SHOULD have a baseline for a good comparative study .... look to the ER Doc first THEN minus paralytic's, in the cold, in the wet, in the dark, in a bathroom, on the floor ... hey this is begining to sound like a Dr. Suess book.

Horton Shoots a tube .... I digress.

cheers

[tniuqs]

R/ r911

[VentMedic]

Perhaps the choices for those ER Docs are definitive just airway management, if one has experiance with ventilalators one knows that these rescue airways have to changed out they are only a stop gap. The ventilators are all closed systems, a leak with return volumes can be a nightmare to set low Vt and MMV alarms. I think also one other item was left out the bronchoscope and the Gas Passer up in the OR, (the Airway Rescue Specialist) and always willing to drop down to provide a helping hand.

We will not risk the chance of putting an alternative airway on mechanical ventilation. The chances over extending the gut to where serious damage from over extension, impaired ventialtion and aspiration can occur even with an OG or NG in place. Even if the Combitube is in the tracheal, we will change out as soon as possible to prevent cord and soft tissue damage. Some of our smaller EDs have access to a bronchoscope from the OR, ICU or RT dept and somebody in house knows how to use it if the ED doc is a moonlighter or "rent-a-doc".

If more Paramedics learned how to consistently assess a difficult airway some scoring system such as LEMON or Mallampati score, there would be less trauma done with repeated attempts and reporting their findings while in the field can get the ED moving on the right equipment or personnel for the job. The scoring should be done before any RSI attempt is made in the field if you recognize some feature that is going to give the intubation process difficulty. Assessment for degree of intubation difficulty is like any other skill. Some paramedics don't even get the education on airway difficulty assessment and it is usually taught as "just go for and keep poking until you get it".

The use of OG and NG tubes should also be utilized by some paramedics if extended BVM or when there is a chance of vomiting from air or other stomach contents.

Too often we'll get a patient who has been butchered in the field to where we have to use packing to control the bleeding just to get the scope thru the cords. Many times some of these patients end up trached because of the damage and their cords many never function properly again. The G-tube may also be a realty in their from impaired swallowing. This may have a profound effect of some of the younger patients' lives like college students who get intubated for airway protection after a frat party with large amounts of alcohol.

ETI Benefits cuffed seal prevents most aspiration ( post intubation only though )

One misconception to clarify: ETTs and trachs that have cuffs DO NOT seal to prevent aspiration. Cuffs seal to assist in ventilation and should not be over inflated with the notion that less vomit and blood will enter the lungs if you put more air into the cuff. The cuff itself can do a lot of damage if mismanaged.

The cuff is located below the cords and anything that gets past the cords is ASPIRATED. The ETT cuff just slows the inevitable and makes it easier to get the secretions out of the lungs. Many EDs and definitely the ICUs are using the subglottic suction ETTs which are part of VAP protocols and is also why you may see a doctor or RRT changing out your field tubes shortly after arrival.

Note: Pedi and neonatal tubes do not have cuffs.

[p3medic]

Actually you can get cuffed pedi tubes, in fact the local childrens burn center prefers we use them for children with inhalation injury.

[VentMedic]

Actually you can get cuffed pedi tubes, in fact the local childrens burn center prefers we use them for children with inhalation injury.

But, they are NOT to prevent aspiration. They are meant for a specific application with a ventilator. There are also size 3.0 tubes with a cuff for these purposes but only used in extreme cases.

Cuffed pedi tubes should not be placed in the hands of practitioners who don't understand cuff/tracheal pressure relationships and don't have the ability to monitor the pressure.

The practitioners that use a cuffed pedi or neo tube to make up for their inadequacies of choosing the correct tube size also should be banished from any airway management duties until they are re-educated.

That blurp about cuffed tubes in pedi that the AHA put into their guidelines should not be a substitute for not understanding what happens when one doesn't know the consequences of good airway management.

[p3medic]

Nope, they are not cuffed to prevent aspiration, just pointing out that there is such a thing to those who might not have known otherwise.

[tniuqs]

The cuff is located below the cords and anything that gets past the cords is ASPIRATED. The ETT cuff just slows the inevitable and makes it easier to get the secretions out of the lungs. Many EDs and definitely the ICUs are using the subglottic suction ETTs which are part of VAP protocols and is also why you may see a doctor or RRT changing out your field tubes shortly after arrival.

Query: Vent ... I do not know the VAP protocols perhaps its the abbreviation but always great advice from yourself. The newer subglotic suction ports are a great idea, wish all ETT tubes had them, well in a perfect world.

For those of you that believe the ETT is fool proof for micro aspiration, (hence the long term effects of ventilator acquired pneumonias) So take an used tube and place 8 to 10 cc of air in it ... make a circle with your fore finger and thumb, around the cuff .. you will notice small wrinkles ... thats the problem the cuff does not occlude in the manner of a perfectly round shape like in the books.

One of the biggest problem's I saw working in ER was exactly as Vent describes ... these are low pressure cuffs not like "Old RED" ! A MOV (Minimal Occluding Volume) should be a technique that is taught and not a certain volume or pressure (for the field) the incidence of tracheal stenosis with longer term transports I suspect would be far lower, this very easy technique and should be standard practice .... IMHO.

cheers

[VentMedic]

[For those of you that believe the ETT is fool proof for micro aspiration, (hence the long term effects of ventilator acquired pneumonias) So take an used tube and place 8 to 10 cc of air in it ... make a circle with your fore finger and thumb, around the cuff .. you will notice small wrinkles ... thats the problem the cuff does not occlude in the manner of a perfectly round shape like in the books.

The seceretions that hang on to that cuff are pretty nasty in appearance and order also when we finally pull the tube several days later. Unfortunately some of them get knocked off as the tube comes through the cords.

That example can also mimic the pressure in the cuff as the trachea and ETT size varies. Not everyone needs 10 cc of air in the cuff. A very small tube for a large patient can also need more. Different tube cuffs also have different requirements so some recipes aren't always the best or apply to all tubes. (More reasons I dislike the Combitube)

We also have to be extremely cautious putting or pulling a deflated cuffed tube (if one is ever used) through the cords of a child. The extra width and roughness of the cuff can severely damage the cords. Again, only very skilled practitioners should be doing this.

A typical inhospital (or extended transport) VAP bundle includes:

* two-hour oral care

* subglottic or at least pharyngeal suctioning of pooled secretions

* head of bed elevation 30 degrees to 45 degrees on all intubated patients

* reverse Trendelenburg position for patients with femoral lines or on intra-aortic balloon pumps to achieve increased head of bed effects without compromising femoral site integrity as well as spinal or TBI protocols

* deep venous thrombosis prophylaxis

*prophylaxis for peptic ulcer disease.

We also use OG tubes instead of NG on intubated patients and try to avoid nasal intubation totally. Nasal tubes from the field also get changed quickly.