Nasotracheal Intubation of Apneic Patient

[twist27896]

Hi,

So I ran into an interesting scenario today at work. We were on scene at a code and the patient presented with clenched teeth which we had no luck in intubating. We have no RSI protocol in our system... As my partner raced back to the truck to retrieve the cric kit and IO drill (we didn't know we were walking into a code) and the first responders were taking care of BLS I decided I would try the "absolutely contraindicated" nasotrachael intubation of our apneic patient (As an EMT-Intermediate I cannot do surgical airways). It went right in and functioned perfectly within about 8 seconds. My partner finally got back and was was shocked and confused about how it worked with no inspiration to guide it in. I guess I attribute it purely to luck but it got me thinking-- In classes and from talking to MDs and respiratory therapists, you cannot and should not ever try to go nasally with an ET tube on a non breathing patient (indeed I got chewed out at the ER). Does anyone else have any experience on this issue? I know the procedure is not intended for code situations, but it seemed to work so easily and quickly to be so harshly contraindicated in this situation. Obviously if other more reliable and indicated means were available (surgical procedures, RSI, etc.) that would be the better option, but what about if they are not readily at hand or a paramedic level provider is not present?

Edited February 4, 2013 by twist27896

[cykes02]

I'm perplexed by your post. The first thing I can offer is yes, it was probably dumb luck that your nasotracheal intubation attempt of an apneic patient was successful. That being said, good for you. You thought outside the box and improvised when conventional measures failed. Was it contraindicated? Yes, but I would argue only relatively. If the goal is to optimize oxygenation, which it is, you succeed. Two questions remain. The first is for your service: why isn't your surgical airway kit with the rest of your advanced airway equipment? You just learned a hard lesson and that is you cannot always predict the failed airway. You can assume a difficult airway, which you did, but did not have the appropriate equipment prepared when you needed it in a hurry. The second question is a physiological one: why was this patient clenched? Trismus is normally associated with muscular contraction, which should cease actor shortly after the time of cardiac arrest. Paralytics used in RSI should provide no benefit in the case of arrest because the patient should already be relaxed as muscles cannot contract without oxygen (for very long) and oxygen is not supplied without circulation, nor is carbon dioxide eliminated, which will further, indirectly, lead to the absence of a muscular contraction. Yes, I'm aware that there is a lot more that goes into the function of skeletal muscle but that's beyond the scope of this comment. My only other comment, and you may have just not mentioned it, is don't forget the basics. A nasal airway and a BVM make a very effective bridge to definitive airway placement in the clenched patient, in most cases assuming the absence of secretion or emesis and an adequate mask seal. I'm sure you thought of it but never neglect oxygenation for the purpose of airway placement. The airway does nothing to affect outcome if we allow hypoxia, especially prolonged hypoxia, in the interim.

[DwayneEMTP]

Brother,I'm confident that this is a theoretical question posed as first person fact, for the reasons mentioned above as well as others...

Great response Cykes!

[twist27896]

I agree 100% that we should have our surgical airway stuff in our jump bag, but I guess due to budget constraints we only have one kit on the truck in the airway cabinet. The first responders had already placed an NPA while we were setting everything up. I am sure that the success was blind luck but my question is, should you ever try to do it in a similar situation? I mean every piece of literature, protocol, and advice says no but if it worked once and you are between a rock and a hard place, would it not be something to at least consider? As far as why the teeth were clenched we don't know unfortunately. The only history we were given was a methadone abuse and hx. of back surgery. I'm not a paramedic so I don't really know that much about RSI actually but I guess for non-code situations it might come into play? I could be missing ALOT of something here since I am not at the full Paramedic level which is what I am wondering.

Edited February 4, 2013 by twist27896

[ERDoc]

Even a broken clock is right twice a day, so be careful with that line of reasoning. Don't forget that not everyone needs a definitive airway. If you can oxygenate/ventilate with an NPA/BVM, then don't fix what ain't broke. Another question I have, is what was the cause of the code. Was this an OD? Would the pt have benefited from narcan? What do you mean by "code"? I've come to find that different people have different definitions.

[twist27896]

We don't really know the cause unfortunately. We gave the usual round of code drugs (including 2 rounds of narcan). The medic and doctors wanted a definitive airway so that was really the only reason I that I tried to get one than avoiding aspiration and reducing gastric air. As for it being a "code", it was an unwitnessed cardiac arrest in asystole. We walked into a report that the patient had "fainted".

Edited February 4, 2013 by twist27896

[Just Plain Ruff]

How long was patient down again? Why did you transport Asystole? Just asking, not confronting?

[Kiwiology]

I think it might have been easier to just not commence resuscitation, or to have ceased. Asystole with two rounds of adrenaline ain't looking good.

In the absence of such and if a definite airway was desired then whoever desired it should have performed the procedure.

Curiously, what did you want?

Personally, I reckon an NPA with a good jaw thrust or an LMA would suffice quite nicely

[twist27896]

We are working on being allowed to call asytole in the field but as of now we have to work it and transport for the ER to discontinue resuscitation unless obviously dead :\ We don't carry LMAs and we couldn't get the mouth open to use a normal adjunct. NPA was working and seemed to be effective. Just wondering if anyone has done this before and/or where there stance is on apneic nasal intubation. Pt was down for maybe 10 min? It was unwitnessed so it is kinda uncertain.

Edited February 4, 2013 by twist27896

[paramedicmike]

Everything I'm reading, and have ever read, about nasotracheal intubations has stated that the patient must be breathing to facilitate tube placement. Given what you've posted here I think you simply got lucky with the tube placement. I would not count on that happening again.

Without trying to distract too much from your original question I think you've unwittingly raised some excellent questions and discussion points. Was there a functioning NPA with effective bag mask ventilations ongoing when you arrived? Current ACLS guidelines don't advocate for advanced airway placement if effective bag mask ventilations can be maintained. If you're being forced to transport then maintaining effective BM ventilations can be difficult and I can understand the desire for an advanced airway. However, your comment about "obviously dead" makes me wonder if perhaps a phone call to your command doc with an explanation of an unwitnessed arrest, unknown downtime, asystole in three leads, and two rounds of drugs with no ROSC would meet your stated criteria for "obviously dead".

I'm interested to hear if CHBARE has any additional insight on the nasotracheal tube discussion.