Supraglotic Airways and ICP

[NYCEMS9115]

You do know the golden hour does not exist?

You do know that an improperly fitted hard collar will cause jugular venous compression, increased ICP and decreased CPP?

You do know that hyperoxic/hyperoxaemic states cause the small precapillary sphinceters/aterioles to constrict?

You do know how difficult OPA and BVM will be for a prolonged period of time?

So forget the basic adjunct, basic ventilatory support, and cervical collar. You have to explain. I guess I have to explain properly fitted cervical collar; not everyone is a no-neck. Also, if the patient is breathing; ventilate when they breath but do not forcefully ventilated them. If the patient has a gag reflex; do not insert an OPA. Expedite to the ER; no hanging out, chumming with the Police or the cute Firefighter; or the hot sobbing friend because prolong immobilization can lead to hemostasis and can lead to emboli. In addition, even if the patient accepts the OPA; it may still stimulate a subtle gag and increase ICP. Lastly, if the Cervical Collar is not a near perfect fit; the slight movement of the neck or side to side motion can increase ICP.

We're talking about the Paramedics who have to get the line and tube; even after several attempts. No sense of urgency; no concept of quick and appropriate BLS Care on scene and ALS Care enroute to ER unless the ALS Care is to treat ABC life threats.

Thanks.

Trauma Patients need a Surgeon. These patients just need a quick ride there. EMS Providers need to see that; in the U.S. that is.

Is that quoted from a protocol book?

I think if your gonna get a decent canvass of what your options are in managing this patients airway, your gonna have to give more details as to the patients presentation. There is a point where you intervene and theres a point where you can manage without sticking anything in their gob, its a little unclear as to where we are with this pt.

Is that quoted from a protocol book?

I think if your gonna get a decent canvass of what your options are in managing this patiewnts airway, your gonna have to give more details as to the patients presentation. There is a point where you intervene and theres a point where you can manage without sticking anything in their gob, its a little unclear as to where we are with this pt.

If you can RSI then that's different. Trust me, I've asked for RSI for Traumatic Patients in NYC but the argument has always been; hospitals are no more than 5mins away. Not if hospitals keep closing; its not like traffic will move for you, many people will not exit the elevator for you to get in; a lot of homes are cluttered and egress to the patient is a slow process; and many other factors that make the 5minute ETA to the ER absolutely false. Currently, we can give Etomidate and the Benzodiazepines; the patient can be sedated if enough is given but the Protocol doesn't put weight and the patient's health into consideration. The patient is never really fully sedated. My Proposal was for severe Head Trauma when RSI can be applied but there must be a strict criteria, strict documentation, forms that need to be filled out, and a QA/QI. The Exec Dir told me that the Council reviews many things but only Board Members can suggest ideas. Us pawns can make suggestions; if the Committee asks; there is a form that we can fill out and send to the Region; if they ask...

Of course Paramedics must be trained in this; the SLAM Course would be an option...

[chbare]

Have you looked through the pre-hospital RSI literature? Aside from a few beacons of light, much of it is pretty bad for the home team. Why should we expect medical directors to give us RSI protocols when the risks are high and benefits questionable?

Take care,

chbare.

[paramedicmike]

Have you looked through the pre-hospital RSI literature? Aside from a few beacons of light, much of it is pretty bad for the home team. Why should we expect medical directors to give us RSI protocols when the risks are high and benefits questionable?

Take care,

chbare.

This 1000%. Those few beacons of light CHBARE mentioned are usually limited, too, to flight services or really small services with very aggressive training, continuing education requirements, exceptionally tight medical command oversight and rigorous QA/QI procedures in place.

[bizar.one]

i definately agree with the whole RSI, ET tube placement... sometimes you do have to think about your basics first... what ever adjunct that is going to help you stablelize an airway... secondly the vagus nerve originates at the bottom of the brain so if you are worried about vagal stimualtion think again the increased ICP will take take of that for you... ICP and TBI is a great risk that alot of these trauma patients face.. most of it you can control on the rate of oxygenation (ventilation)...... RSI definately will help include narcotics as part of your sedation... Fentanyl works great premedication will help as to not have a spike on BP, HR and oxygen demand does not increase. therefore not elevating ICP.

[chbare]

Not sure I follow your vagus nerve statement? If you have supratentorial haemorrhage/mass effect/swelling, the vagus nerve very well may not be involved.

Take care,

chbare.

[Kiwiology]

So forget the basic adjunct, basic ventilatory support, and cervical collar. You have to explain. I guess I have to explain properly fitted cervical collar; not everyone is a no-neck. Also, if the patient is breathing; ventilate when they breath but do not forcefully ventilated them. If the patient has a gag reflex; do not insert an OPA. Expedite to the ER; no hanging out, chumming with the Police or the cute Firefighter; or the hot sobbing friend because prolong immobilization can lead to hemostasis and can lead to emboli. In addition, even if the patient accepts the OPA; it may still stimulate a subtle gag and increase ICP. Lastly, if the Cervical Collar is not a near perfect fit; the slight movement of the neck or side to side motion can increase ICP.

This is almost the worst case of fail I have ever seen!

We're talking about the Paramedics who have to get the line and tube; even after several attempts. No sense of urgency; no concept of quick and appropriate BLS Care on scene and ALS Care enroute to ER unless the ALS Care is to treat ABC life threats.

Thanks.

Trauma Patients need a Surgeon. These patients just need a quick ride there. EMS Providers need to see that; in the U.S. that is.

... and it gets stronger.

You do realise "BLS" and "ALS" are not actual things right, you know, things that mean something? They are backwards nonsensical words that mean nothing and are foreign to medicine yet are held so dear by the Americans as if they are some sort of Biblically inspired concept?

Go do some research, trauma is an increasingly non surgical disease.

[NYCEMS9115]

This is almost the worst case of fail I have ever seen!

... and it gets stronger.

You do realise "BLS" and "ALS" are not actual things right, you know, things that mean something? They are backwards nonsensical words that mean nothing and are foreign to medicine yet are held so dear by the Americans as if they are some sort of Biblically inspired concept?

Go do some research, trauma is an increasingly non surgical disease.

Not sure why your targeting my post(s) and claiming I need to do research; as if what I've posted isn't true. My post was an evaluation of what I've seen and what some Providers have come across. Poorly fitted collars; no necks for all (patient 6'2" 190lbs, not a no neck). Apparently, arms are pin cushions; several needle sticks without an IV established and the need to establish one (we're running out of large bores, here's the last 22g). On-scene time exceeding 20, 30, 40 minutes because the desire to make sure all Protocol Care and Assessment has been rendered before transport; no understanding of "the sooner you leave the scene, the sooner you'll be in the ER; care can be given in a moving Ambulance."

You must inform me of the non medical terminology of BLS and ALS in other Countries but you can only speak for your Country (even though you are not a recognize Representative of your Country and neither am I of mine) but please tell me without insulting. I know it is hard. Since, most on the site trash others opinions...

[usalsfyre]

You must inform me of the non medical terminology of BLS and ALS in other Countries but you can only speak for your Country (even though you are not a recognize Representative of your Country and neither am I of mine) but please tell me without insulting. I know it is hard. Since, most on the site trash others opinions...

While I don't claim to speak for Kiwimedic, EMS is the ONLY place in medicine I've encountered the "ALS" vs "BLS" nomenclature. And it's really a pretty ridiculous division. Elsewhere it's medical care, and you do as much as your educated and credentialed to do.

[NYCEMS9115]

While I don't claim to speak for Kiwimedic, EMS is the ONLY place in medicine I've encountered the "ALS" vs "BLS" nomenclature. And it's really a pretty ridiculous division. Elsewhere it's medical care, and you do as much as your educated and credentialed to do.

We provide Prehospital Care not Medicine. In NYS, that is. We are Practitioners of Prehospital Paramedicine not Medicine. A Nurse/RN doesn't practice Medicine. A RN practices Nursing. They are Practitioners of Nursing Care. BLS and ALS are Prehospital Care in NYS, that is. Can't argue something that is fact in one region. I'm disputing other's idealism because I'm not from there, so I can not. EMS as a whole is not egocentric; we are different and the needs are different (for the most part). Medicine are for Physicians... Nurses and Allied Health Professional practice a sub-category of that... Ridiculous is a strong word...

[paramedicmike]

So that "M" in "EMS" doesn't really belong there?

With regards to splitting care to BLS vs ALS, I don't think the word ridiculous is strong enough. Moronically stupid is more appropriate but less PC.