Nasotracheal Intubation of Apneic Patient

[ClutzyEMT]

You seem to be missing a lot of details on "your" call which perplexes me....I also would like to know how long the pt was down before you arrived. Are you sure he hadn't been down so long that rigor had set in? Rumor has it that it starts in the jaw first....just a question mind you....

You also state that First Responders were taking care of BLS...I'm guessing that means they had the AED attached and were performing high quality CPR all with an NPA in place that was efficient?

Which brings me to my question then of why you would even take it upon yourself then to decide this wasn't adequate and go against "absolute contraindications" to use nasotrachael intubation while a higher level provider "ran out to the truck to get the IO and cric kit"...I'm just having a hard time swallowing this statement.

In my neck of the woods if the medic wants a more secure airway, the medic gets a more secure airway and doesn't request that another provider goes against contraindications and protocols to obtain one....I'm not real comfortable with your statement that you attribute it to "pure luck" and doesn't give me a warm fuzzy feeling that someone who appears to be so blatantly proud of going against proven procedures is providing care...

I agree with ERDoc that even a broken clock is right two times a day~~

[ChaseZ]

So what would have happened if you tubed the stomach? Would you have just pulled it out? Left it in place? Documented the attempt?

[Arctickat]

Woulda left it in place to block the hole and shoved another tube down the other nostril.

I finally have a couple of days off so this might be the vast quantity of Irish Coffee talking...but wtf is an intermediate provider doing a nasotracheal intubation for anyways? Is there anyplace where ETT placement is an Intermediate skill, let alone NTT? Methinks someone is very lucky he doesn't have stinging fingers 'cause I sure as hell would have rapped them before kicking is ass out of my organisation.

Edit, I meant to put Intermediate and had BLS in error.

Edited February 5, 2013 by Arctickat

[scubanurse]

Hey now, he said he was an Intermediate... I'm also having a lot of problems with this call. Why would someone who has been down for an unknown length of time have a clenched jaw... I've seen this in head trauma but relaxes promptly with the loss of a pulse. Can someone explain a physiologic condition (other than rigor) that would cause this?

I've never heard of a jurisdiction that does not have a DOA protocol... if this was rigor did you just mess with a potential crime scene?

Why would you just for the hell of it try a NTT without your medic partner there, stopping CPR and effective ventilations?

There is just stuff that isn't adding up... did you document you placed the NTT? What has your medical director said of all this?

[island emt]

Yes Kat there are many places where Intermediates can intubate and have for many years.

Properly educated and trained it has been a standard of care for over a decade.

I would not have even thought about pulling the nasal airway to try a blind insertion nasal ETT on a dead guy, especially given the unknown down time and the drug abuse hx. He would have gotten CPR, IV ,a couple rounds of epi & narcan to try & reverse a potential opiod causation of the arrest.

After 20 minutes call it right there.

Dead guys don't often get better.

PS. I have run into a narcotic overdose arrests with trismus.

[ClutzyEMT]

Actually Kat, ETT is in my bag of skill sets although in all honesty, the only time I've used it is testing and for skills maintenance. I have used Combi-tube as my first "go to" airway everytime......

NTT however is not and I can not find it in any of my surrounding state Intermediate protocols....

I think I'm sticking by my original thought that this question is a pose as there seems to be too many details that do not add up....

[twist27896]

Hey guys, I'll try and clear up some questions. In NC EMT-I's can intubate orally and nasally in many places. I honestly don't know why trismus persisted (it might have very well been rigor--I honestly don't know) although rigor didn't appear anywhere else that we could tell. The down time was heavily estimated as the arrest wasn't witnessed. We are in a transition phase with a new chief and policy overhaul and they temporarily took away the ability to terminate resuscitation unless rigor has obviously set in, DNR, or trauma inconsistent with life. The only thing we did know for sure is about the drug abuse hx. I am definitely not proud or "happy" that I did something in a grey area just wondering if anyone has ever heard of it being tried before.

[DwayneEMTP]

I'm surprised that chbare hasn't chimed into this conversation yet.

I don't know why it's contraindicated, but my guess would be that the odds of it being necessary would be almost nonexistant, particularly having such a patient as mentioned here, as well the odds of success being dismal, combined with the damage that someone that would try such a thing would likely do to the airway anatomy while they bashed the tube around hoping for their "lucky shot."

Chbare tells us that tons of damage is often accidently done by paramedics doing normal ett placements, I can't imagine that doing blind netts would be any better, and almost certainly worse.

[J306]

Since the circumstances of this call make no sense to me right now, to be clear, your ACP partner went back to the ambulance, leaving the you, the lesser qualified practitioner to get the cric and IO kits before knowing that the patient was in cardiac arrest and before even assessing the need for a surgical airway or attempting an IV? This makes no sense.. This must be a hypothetical situation of some sort.

[Spock]

There are many good comments already and all I can do is confirm what has been said. Getting the nasal tube into the trachea was pure dumb luck and will happen once in a hundred times. There are many ways to manage an airway effectively and having a tube in the trachea is only one of them and it is not high on the list. The AHA ACLS materials have lowered the emphasis on getting the patient intubated because it all to often interrupts compressions. Requiring transport of a patient in asystole that has not responded to aggressive ALS interventions is also not recommended by the AHA.

Obvious signs of death? Asystole and clenched jaws that can't be opened? Can anybody say rigor mortis?