Nasal intubation and no ventilatory assistance????

[medic30_james]

Hey guys,

A crew in my service nasally intubated a very intoxicated patient. They say it was to protect their airway because she was already vomiting. The pt was breathing adequately so they just placed a nonrebreather mask over the end of the tube, and never provided any positive pressure support.

I have my opinions on the matter ( I would have bagged the pt), but what do you think. Would the crew members encounter any repercussions in your service area?

Sincerly,

Works in a weird place

[Arizonaffcep]

I could see this if it was an NPA...not a tube. Was this person's GCS less than 8? Drunks vomit all the time...it's a subspecialty for them (liver failure being primary). Ok...not really, the hard core people don't really puke, the newbies do. If they are able to maintain their airway and clear it themselves after each episode, then there was no reason to intubate. If, however they couldn't clear their airway after each one, fine...but they would be so stuporous their respiratory drive would be affected--meaning they would need to be "bagged." Just please tell me this was not a punitive intubation.

[medic30_james]

Intubation was not punitive, the pt was very obtunded and they wanted to protect the airway

[Arizonaffcep]

If you would remind them that the little white plastic thing at the "external" end of the tube hooks real nicely to the end of a BVM...and not so well to a mask

[VentMedic]

What size was the tube? Small tubes and/or tight nasal passages = increased work of breathing which sets a pt up for failure or quick decompensation. Even a good sized tube has resistance that must be overcome and thus that is why we have all sorts of tube compensation modes on ICU ventilators.

Any amount of secretions can further block the tube either partially or completely and pt can quickly decompensate without one knowing in the back of a noisy truck and the pt covered by clothing or sheet. Dramatic SpO2 change may be late and after pH has fallen with the rise of PaCO2 especially if the patient is in a hyperoxygenated environment like a NRBM.

Was there an ETCO2 monitor in place? A pulse ox will tell nothing about the patients ability to clear CO2. Was the nare adequately prepped prior to intubation? Blood from the nasal intubation may also hampered effective gas exchange.

If the patient was obtunded they may already have had impaired gas exchange. The respiratory effort once the airway was open may have been an attempt to decrease a possibly high PaCO2 level that had already accumulated and increase their pH out of the danger zone.

Respiratory effort can be deceiving especially with impaired mental status.

It is rare that we intubate anybody for alcohol unless they are apneic or a child with a toxic level.

In the hospital, it is very rare to see a nasal intubation due to the high risk of infection and damage. If a patient is being weaned from a ventilator or post op, they may be on a T-Piece but the tube size is very adequate and ABGs give baseline while ETCO2 is monitored. Even that is rare due to safety issues and newer ventilatory modes on ICU ventilators to mimic a T-Piece which monitor the airway resistance with the appropriate alarms in place.

Many, many years ago in the hospital, we used to leave the tubes in comfort care patients when we discontinued life support until it was ruled cruel and uncomfortable care by our medical ethics committee.

[medic30_james]

Was there an ETCO2 monitor in place? A pulse ox will tell nothing about the patients ability to clear CO2. Was the nare adequately prepped prior to intubation? Blood from the nasal intubation may also hampered effective gas exchange.

We do not carry ETCO2 monitors yet on the trucks. yes, we are behind the curve, i know.

[1EMT-P]

I can understand placing an NPA & applying a NRBM, but nasally intubating & applying a NRBM over the tube... :roll: .

[Kaisu]

oops... thought you meant NPA and voted mask ok - (gives head shake - I am within an hour of the last 12 of a 72 hour shift...)

makes no sense to intubate and not bag...

[sjslennon]

I just finished a shift so please excuse me if I am misreading your post -

The crew put a tube in her airway such that the ONLY way to ventilate the pt was through this tube, but the only oxygen they gave her was supplied by a NRB placed over the tube??? The crew should be informed that it is possible to bag a pt who has spontaneous respirations.

I won't criticize the decision to intubate because I don't have enough information to do so, but it is hard to imagine a scenario where this is appropriate. Was she vomiting so much that there truly was no way to suction the vomitus? Was it clearly established that there was no head injury (ie, contraindication to nasal intubation, one cause of vomiting, not surprising with obtunded drunken pt)?

Most pts with a GCS less than 8 are not difficult to intubate orally, in my experience.

[sirduke]

Duh........ bag them.