Nasotracheal intubation

[StreetDoc2426]

This thread was inspired by the "hurricane" thread, which ak had already locked. I was surprised to read peoples posts about how odd it would be to intubate a conscious patient. We routinely employ nasotracheal intubation in conscious pt's in severe respiratory distress, as well as the unconscious "but breathing" people who wont arouse with pressure points, ammonia, etc as a means of protecting the airway from aspiration. In short, I've hosed my share of drunks. This year I've dropped 6 so far,,,think imma try to keep a running count this year.

Just wanted to see if others do this as well?

[Ridryder 911]

In my opinion nasal tracheal intubation is basically the same as oral intubation, either with spontaneous respiratory drive or using magills. The same true as digital intubation, on trauma patients. Intubation is intubation, putting a tube int tracheal opening..no big deal. Intubation should occur when ever the patient needs to have the airway secured or unable maintain ventilation & perfusion (V/Q ratio)...just common sense & normal airway control....

Be safe,

R/R 911

[Dustdevil]

I did not mean to imply that conscious intubation was a rarity in the other thread. I was saying that it is extremely unlikely to be peformed by a basic.

To clarify your point, are you saying you use topical anaesthetic spray for intubations in your system?

[AZCEP]

Nasotracheal intubation is faster, and easier-with the right tools-, than most any other airway technique out there. Yes, RSI makes things OPTIMAL, but so many systems don't have it that the nasal route is all that is left. Even with a sedated patient, oftentimes they won't be down enough to allow for an oral attempt. When this happens they get a hose in the nose.

The "hurricane" spray is right handy, but not required. Some use the viscous lidocaine, but more for the lubrication than the anesthetic effect.

I will mention two things, 1)Use an Endotrol tube. The guidewire that is built into it makes things so much easier for you. 2)Invest in the BAAM whistle. This little device makes the breath sounds audible over most anything. There have even been cases where I have suspected a pneumo- by listening to the different sounds of the whistle.

If anyone is managing an airway, it is always preferrable to have more options that you know how to use, than to be limited to a couple that you aren't sure of.

[nsmedic393]

We do naso-tracheal intubations. I wish we had endotrals. I usually just hook one end of the tube around and stick it into the other end, forming a circle, and leave it that way while i prepare the rest of the equipment. That way at least the tube has a good curve to it. We don't have the whistles either. I just pull the bell of my scope and stick the open tube into the ETT.

[retired_medic61]

I have used this a number of times. For example, I had a CHF patient with a known hypersensitivity to Anectine (causes severe hyperkalemia in him) plus he had no easy IV access to boot. I would make a call on him every two to three months and everytime he waited to the last minute to call for EMS where his breathing became so labored as to warrent a tube. In this situation nasotracheal intubation worked like a charm.

[medic001918]

I will mention two things, 1)Use an Endotrol tube. The guidewire that is built into it makes things so much easier for you. 2)Invest in the BAAM whistle. This little device makes the breath sounds audible over most anything. There have even been cases where I have suspected a pneumo- by listening to the different sounds of the whistle.

+1 on the BAAM whistle. One of the best inexpensive tools to carry. It works great. If your service doesn't carry them and you can't find one, you can take an ETCO2 detector and put it on the end of the tube as you nasally intubate. As you get closer to the trach, the reading will go up and the waveform will look more organized. It's less than ideal, but effective none the less.

Shane

NREMT-P

[Rsmith398]

Our service does have the option of RSI or a Nasal tube for patients. It is normally up to the decision of the medic and his view on the pt condition. We do not tend to put down someone in CHF or exacerbation of COPD.

As for an earlier post, the use of topical medications for nasal intubation. We do use them.. we use several things to help facilitate the tube going in a little easier. First we use something such as Afrin to help with the vessels and reduce bleeding; next we use liquid lidocaine out of tube to shoot it up into the nose and down the back of the nasophrynax. Then a Nasal Trumpet is use with lidocaine jelly on it to help numb up the passage a little more and help dilate the nare we are going to use. The trumpet is removed and the tube is inserted with lidocaine jelly on it for lubrication of the tube also.

In the past this seems to work and I have had some patients who will ask for it, rather than suffering with the condition that they may be dealing with.

[firefighter523]

We are taught to use cricoid pressure, while we are advancing the tube, (one size smaller of course). I elected to do it once in the field (precepting) for a benzo od. (It was a known benzo od, we knew that the narcan wouldn't change anything). The cricoid pressure worked like a charm. She was silent, and all of a sudden she started whistling dixey!!

[Dustdevil]

It was a known benzo od, we knew that the narcan wouldn't change anything.

You watched her ingest it? You identified the pills before she ingested them? That's pretty rare!