Nasotracheal Intubation of Apneic Patient

[Just Plain Ruff]

Obvious signs of death? Asystole and clenched jaws that c

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

Well the clenched jaws could have been that he had broken his jaw, then had it wired shut. Hey it's as likely as getting a nasal tube on a asystolic patient right?

[Arctickat]

I'd be interested in discovering how much trauma resulted from the airway insertion.

[Spock]

Got a good laugh from that response Captain!

[fab]

While certainly not best, 'blind' nasal intubation still remains common practice. I've done one of my clinical rotations in the anaesthesia department of a maxillo-facial surgery unit where most ETIs were done nasally. I was shocked (on my first day) to see the senior anaesthetist simply 'shove' the tube down the patients nose without even touching the laryngoscope (and stethoscope for that matter). Still, I haven't seen any of his intubation attempts fail... Some of the other consultants used the same technique. Trick is not to tilt the head backwards, basically get it into a Jackson kind of position.

Mind you, these guys had 10+ years of experience doing exactly that day in, day out. I'm fairly certain none would attempt it in a code situation.

Now the interesting question is, why was the jaw clenched??? Any kind of trismus would cease during arrest, possibly the clenched jaw was due to surgery or radiation therapy? To be honest, Spock is probably right.

[chbare]

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.

I'm sorry bro, not much else I can add to the conversation. Clearly a patient with spontaneous respirations will be a better candidate for NT intubation. However, in light of all the evidence, I am not sure anything beyond a nasal airway and conventional ventilation would have been really indicated in this situation assuming the apparent trimsmus was not rigor mortis.

[Spock]

Fab makes some interesting points. We do a lot of OMF cases that require a nasal tube and at my hospital we have used and interesting technique with a glidescope (video laryngoscope). The tube is advanced through the nares and then the glidescope is inserted and the vocal cords are identified. The tube is advanced and then the balloon is inflated which elevates the tube such that the tip of the tube is placed into the trachea. The balloon is then deflated and the tube is advanced deeper into the trachea. It works well and beats the hell out of using the Magill forceps to place a nasal tube.

I would never try this in a code situation nor would I choose a nasal intubation. Nasal airway and BVM as chbare suggests is the way to go.

[nancybell]

In all my years of EMS work, I have never had anyone nasally intubate nor have I ever used nasal intubation in a code. I am old school the only way I would ever had considered that would be last resort to save a life. Apparently from your senerio there was no chance of that. Is there anything in his medical history that might explain that? I would also like to know the medications he was on.

Those last questions deal with the trimsmus.

The brain was working faster than the fingers.

Edited March 7, 2013 by nancybell

[DwayneEMTP]

While certainly not best, 'blind' nasal intubation still remains common practice. I've done one of my clinical rotations in the anaesthesia department of a maxillo-facial surgery unit where most ETIs were done nasally. I was shocked (on my first day) to see the senior anaesthetist simply 'shove' the tube down the patients nose without even touching the laryngoscope (and stethoscope for that matter). Still, I haven't seen any of his intubation attempts fail... Some of the other consultants used the same technique. Trick is not to tilt the head backwards, basically get it into a Jackson kind of position.

Mind you, these guys had 10+ years of experience doing exactly that day in, day out. I'm fairly certain none would attempt it in a code situation.

Now the interesting question is, why was the jaw clenched??? Any kind of trismus would cease during arrest, possibly the clenched jaw was due to surgery or radiation therapy? To be honest, Spock is probably right.

Good points, but I am willing to bet that not a single one of these nasal intubations, unless assisted visually in another way, was done on apneic patients, right? There is good reason that we nasally intubate breathing patients only. I've done a half dozen nasal intubations now and it's not easy, it my experience and at my level of skill.

[ERDoc]

This is probably one area where EMS has more expertise than docs do. I have never done a nasotracheal tube. In the hospital we have so many back ups that it is almost unheard of (either that or I am just that good ). I've seen a handful of nasal tubes come in and I switch them over to orotracheal as soon as possible. I can't say there is a reason other than comfort level.

[Kiwiology]

I don't see a reason to need to do a nasotracheal intubation except in some things like dental or max/fac procedures