Pull the tube?

[zzyzx]

You are dispatched to a “chest pain” at a private residence. As you walk in the door, you see the firefighters doing CPR on a 55 y/o male. The fire medic tells you that this was a witnessed arrest (by the family) with a downtime of perhaps 5 minutes. The patient had been eating dinner when he started having chest pain. He took his nitro with no relief, so his wife called 911. Before anyone arrived, the patient collapsed. When the fire medic got there, he was in fine VF and was shocked once into asystole.

The fire medic intubates and you get the IV and begin drug therapy. There is no change on the monitor. While you’re working the patient up, you notice that the patient’s abdomen looks distended. You point this out to the fire medic, but he says he’s sure he saw the cords, got breath sounds, etc. The patient hadn’t been hooked up to the capnography yet, but this is quickly done and you get a reading of 6 mmHg.

After the second round of drugs, there is no change in the patient’s condition. The decision is made to transport. About 10 minutes later you are close to arriving at the ER, and by this time you see that the patient’s abdomen is HUGELY distended. You are now getting poor compliance from the BVM and you no longer get a capnography reading.

You use an esophageal intubation detector (Tube-Chek), and it reinflates quickly. However, the capnography is still reading zero. Do you pull the tube? What do you do next? What might be going on here?

[AZCEP]

Yes, pull the ET tube and ventilate with a BLS airway for a minute. Consider an NG/OG tube to decompress, and perhaps place a Combi-tube in the interim.

Re-assess lung sounds, throw the EDD in the trash, shake your head at a provider that should have known better. :roll:

[VentMedic]

I can't believe I just read what I read in this case scenario.

[medic001918]

Pull the tube. Ventilate and reintubate. My first thought was that the patient may have been distended from when they were most likely bagging the patient upon arrival. But the end tidal reading can be a false positive if the patient has had anything to drink that's carbonated (such as soda or beer). For a patient that was in v-fib, I would have expected the end tidal value to be higher. I'm also curious as to why the fire medic waited to initiate capnography.

An NG tube is definatly in order for this patient to try to relieve some of the distention in the abdomen as well. That will help to gain better compliance when a tube is inserted correctly.

Shane

NREMT-P

[vs-eh?]

Questions and comments...

1) What is your work policy or "common sense policy" regarding ETT confirmation? Obviously there are multiple clinical and adjunct ways a tube can be confirmed to be in the right place.

2) You as a paramedic noted that you saw something clinically that may indicate that the tube was not in the trachea. Why did YOU not reconfirm the tube or AT MINIMUM ask the paramedic who intubated to do the same?

3) The reading of 6 mmHg ETCO2 if the tube was in fact in the esophagus would have been transient (regardless of anything). Does your system only have numerical display for ETCO2? What did the waveform look like?

4) Is it common for you to transport adult cardiac arrest patients (witnessed or not)?

5) During this movement of the patient and the 10 minute + transport, how many times was the tube reconfirmed? Is it not standard policy (rational policy) after any significant movement of an intubated patient ESPECIALLY in the face of a query INITIAL misplaced tube to reconfirm regularly?

6) What did the patient actually look like?

[spenac]

He should not have been transported w/o re-confirmation of proper placement. Screw the FF medics feelings, if I take over for anyone I recheck everything because they are now my patient and I am responsible. Also every time patient is moved should reconfirm placement.

[itku2er]

Yank the tube and reintubate, This should have been done at the begining. Did you reassess tube placement after the pt was moved? I mean for lung sounds not just rely on the CO2 dector.

[Medic26]

Did you reassess tube placement after the pt was moved?

Basic ACLS, re-confirm after each time the patient is moved. In my mind if there is even the slightest bit of doubt the patient gets extubated and re-intubated.

[chbare]

Yep, should have used the esophageal bulb and capnograhy immediately following the initial intubation. After a few minutes of arrest, I would not expect great end tidal readings. The tube may have been in proper place and we were simply looking at the end result of AAA that decided to rupture; however, I would still pull the tube.

Take care,

chbare.

[itku2er]

Basic ACLS, re-confirm after each time the patient is moved. In my mind if there is even the slightest bit of doubt the patient gets extubated and re-intubated.

I was asking if they did recheck placement......when in doubt pull it out is the way were taught.