Forcing the Tube

[Paramagic]

I probably should have expanded upon my quick post earlier, but I was in a hurry.

Fortunately Mobey has hit the nail on the head. We are not dealing with a well person who will wake up happily with some bagging. We are also not dealing with a person who will be able to bagged effectively without securing the airway better. Intubation seems absolutely indicated in this patient.

RaceMedic, you seem to have mixed up acute cardiogenic pulmonary edema with COPD: I agree with your treatment if this were pulmonary edema (except the diuresis part),

Gastric insufflation is not just a problem when it comes to vomiting and aspiration. It also impinges on the diaphragm, further reducing ventilatory compliance in someone who is clearly critically in need of ventilation.

[RaceMedic]

Magic,

Your right i did get mixed up. I openly admit it and apologize for any other confusion i may have caused.

However i still hold to my initial disagreement with the forcing of the tube, if they had RSI protocol i would have agreed with a tube then. As Beiber originally posted his service does not have RSI protocols. I can not and will never agree that it is better to cram a tube down the throat of a person no matter how old unless they are in complete arrest. Any person that is clearly fighting the tube should not be intubated with out proper paralytics and sedation. It is very stressful on the PT mentally and physically. If the procedure can not be completed properly then it should not be attempted, PERIOD.

As Beiber told the call the PT was responding to BVM ventilations favorably. Since this was the case brought up in the OP then that treatment should have been continued until arrival to the ED where the PT could have been RSI'd properly. Proper airway management with BVM and suctioning are basic skills that are often over looked by the advanced providers including myself.

Race

*Edit*

The Diuresis would be for chronic CHF not acute pulmonary edema. Which in my experience an 80yr old woman would be suffering from and not just an isolated incidence of acute pulmonary edema.

Just my thoughts...

WOW i have no idea where my head was through out this post ... LOL thanks for the catch Magic...

Edited October 21, 2011 by RaceMedic

[Paramagic]

I don't disagree that forcing the tube is a very bad idea. I think that intubating is appropriate, but I too think it's not appropriate to go about it using a tincture of Brutane as opposed to doing it properly.

[RaceMedic]

Agreed...

[DwayneEMTP]

Yeah man, you're right about this...I screwed the pooch. I'd made my response before I knew the working diagnosis, (left my post open while I'd done other things) but even then I was tunnel visioned on, "She seemed to be improving pretty quick." and "Fighting the tube." or something along those lines.

I absolutely agree that she would/might have improved, but would almost certainly not been maintainable without significant, read 'no effort on her part', ventilation support. And that almost certainly required a tube, though of course other factors would play into this decisions. How much did she improve, what kind of compliance were they getting to the bag, how far were they from a hospital appropriate for this patient?

Now, though I rarely base treatment plans on proximity to the hospital, I just really hate intubating the very elderly unless absolutely necessary. If her physiological markers were improving and had become acceptable for the situation with a BVM and O2, in this case I may have tried to maintain her in that manner until one of the smarter folks in RT could have assessed her and made the truly life altering/ending respiratory decisions that are likely in this gals future.

Thanks for the heads up Brother...This is a really good thread!

Dwayne

[FireEMT2009]

This might be a stupid medic student jumping into something he doesn't belong in but here is my thought on it.

The patient was resuscitated without the use of an ET tube or meds. Since COPD is a bronchodilation/inflammation response why not use the BVM already in place to start a neb treatment to get

her lungs back open while giving a corticosteroid such as decadron or solumedrol? The intubation giving versed, valium, or ativan would have given you the sedative properites needed to help the struggling on the tube and you could have used your BVM with a nebulizer and connected it to the tube and given a neb treatment with atrovent, albuterol, or combivent. It is hard to say what my response would have been to this call but I agree with you beiber a ET tube is a patent definate airway as long as it remains in place therefore if you knock out of her respiratory drive, what little she had via the note on your original post then that is what the tube is for. You can always breath for a patient if the drug knocks out the respiratory drive. You have an airway, breathing and circulation can be controlled by the EMT. Without an airway everything else is in vain. I think that if you had given her sedation and then intubated she would have probably done better. But this is a case of God knows what and opinions are flying. Either treatment, the ET tube or BVM is correct in my opinion as long as the proper stages of care are followed such as sedation assisted intubation or noninvasive intubation.

Just a medic students input if worth anything.

FireEMT2009

[RaceMedic]

FireEMT,

Great addition to the threat, thanks for including it. your absolutely correct with alternative treatments as well as your thoughts on the intubation. Of course you will have to stay with in your local protocols and if you have all of those at your disposal i want the number to your service... LOL

But do not discount your input because you are a student. even those of us with yrs under our belt need reminded of things from time to time... Keep posting and taking part.

Race

[FireEMT2009]

FireEMT,

Great addition to the threat, thanks for including it. your absolutely correct with alternative treatments as well as your thoughts on the intubation. Of course you will have to stay with in your local protocols and if you have all of those at your disposal i want the number to your service... LOL

But do not discount your input because you are a student. even those of us with yrs under our belt need reminded of things from time to time... Keep posting and taking part.

Race

We just got Versed here where I am in college for my rotations and our new protocols should be out in the next couple months. Luckly you can hook up a neb to a bvm without much problems as long as you have the T connector and the neb tube and connect it from the BVM to the mask. We do not have decadron here but we do have solumedrol. I am hoping to see that when the new standards for the scope of practice take full effect that it will open up new horizons for our protocols especially for these types of patients so our hands aren't tied up with this situation.

[RaceMedic]

Thats pretty cool, enjoy your rotations .. i miss class but would never do it again.

Solu Medrol is a standard but can take an inordinate amount of time to take effect at times. Does not stop me form giving it though.. also the nebs by BVM is a great thing to remember. However i lost track of what i was thinking early in the thread and was treating CHF/Pulmonary edema instead of COPD... lol

Sometimes not as easy to formulate a treatment plan when it isnt literally in front of you.

[FireEMT2009]

Thats pretty cool, enjoy your rotations .. i miss class but would never do it again.

Solu Medrol is a standard but can take an inordinate amount of time to take effect at times. Does not stop me form giving it though.. also the nebs by BVM is a great thing to remember. However i lost track of what i was thinking early in the thread and was treating CHF/Pulmonary edema instead of COPD... lol

Sometimes not as easy to formulate a treatment plan when it isnt literally in front of you.

Yea i test for my paramedic in April so I am working on my last clinical rotations this semester and will finish up my field run time next semester. The sooner you give the corticosteroid the sooner it will work so it can only help your patient in the long run. And yea not having a "living breathing patient" in front of you makes our field decision alot harder than it already is.