How to manage.

[Paseo Del Norte]

Flight crew called to the scene of a 50-60 year old patient in a rural community found unresponsive by a local EMS crew (EMT-B & EMT-I providers). Unknown past medical or surgical history. Unknown down time. Unknown history of present illness/injury.

Upon arrival:

Patient is supine on the EMS stretcher, appears morbidly obese with an estimated weight of around 120 kg. Pt is unresponsive but taking shallow irregular breaths at around 10 a minute. EMS members are attempting to mask ventilate. Patient is cyanotic and bradycardic. (~50, sinus bradycardia with a normal QRS complex in lead II). Pulse oximetry reads 80%. No gross indicators of trauma are noted. EMS crew have obtained a blood sugar and it is noted at 101 mg/dl. Patient has been place in spinal precautions by the EMS crew. Crew reports multiple unsuccessful IV attempts.

Immediate Interventions:

The responding crew decides to act utilising crash airway modalities and directs the placement of airway adjuncts and initiates good bag mask technique with three providers, good positioning, and cricoid pressure. With some effort the bag mask ventilation increases pulse oximetry reading to 94% and the cyanosis resolves with increased heart rate to 100-110 regular and sinus in origin in lead II. Limited neck mobility is noted due to spinal restriction; however, the collar can be removed with manual stabilisation if needed, good jaw opening is noted, a Mallampati of about III was noted during adjunct insertion; however, a horizontal scar about 2 cm in length is noted to the anterior trachea below the glottic structures. Current blood pressure is 110/70. A rapid head to toe exam is essentially unremarkable and IO access is obtained via an EZ IO system without incident.

Considerations:

The modalities available include: RSI (Etomidate, Sux, & Roc), BAAM whistler, Combitube, King-LTDS, Surgical Cric. kit (optimised for the 4 step technique), Gum Elastic Bougie, & current modalities.

Ground transport time to a small facility with limited resources is 40-50 minutes with a flight time of 15-20 minutes. Transport to a large subspecialty centre by ground is about two hours and about an hour by air.

I would love to see what you guys think about managing and transporting this patient.

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[canjosh]

Gag? Pupils? Narcan given? His supine positioning might very well be his big (pun intended) airway issue.

You have an intubating LMA? If you're competent with the Bougie, it's golden. Especially if you can at least see the arytenoid cartilage.

The patient's vitals are improved with mask ventilation and basic airway maneuvers, don't do anything to screw that up. I'd be leery about even post-intubation paralytics. Head bleed is pretty high in his differential.

 

[Paseo Del Norte]

No change with naloxone. Gag reflex was present and they ended up placing bilateral nasal airways while deferring oral airway placement. Pupils were 5 mm and sluggish bilat. No ILMA available.

 

[canjosh]

Combitube, Versed, Roc.

Transport.

If you're feeling like he'll hold his sats/not puke, attempt one DL then Combitube or your favorite available blindly inserted tool.

As long as there is an intact airway, fly to the tertiary center. If bagging with trumpets x2, would consider the closer facility.

 

[Paseo Del Norte]

Many considerations here. If the patient goes by flight, there will only be two providers for BLS airway management and intubation will be even more difficult aside from the space and limited access issues. However, going by ground utilising BLS modalities will make for a very long trip.

You bring up an interesting and novel approach that is actually being utilised by a service in Albuquerque, New Mexico. The concept of rapid sequence airway (RSA), where an alternative device is utilised instead of endotracheal intubation.

Other things to consider are related to the airway assessment. Morbid obesity, evidence of a prior trach, limited neck mobility, and then provider comfort and skill level. No doubt, this patient is going to be a difficult airway.

I can post what actions were taken and we can discuss?

 

[csmmedic]

Roc and etomidate and intubate. Initial sats were very concerning, and I would really place a premium on protecting the airway in this patient.

 

[MedicFL]

What was this pt's GCS 3? If you RSI this pt and can't get a tube which you should be able to if your RSIing someone. You can always place an airway such as a King Tube, LMA, or Combitube whatever your service is carrying. I agree on not flying a pt without a secure airway. This pt if vitals stablized after an airway was placed then I would try to fly to the speciality center, however if the patient was still unstable fly them to the closest hospital and then stablize them there.. If you cant get an airway on this pt and they start to crash cric them..

 

[Altruist]

That they were able to get oxygenation up to 94% with 3-man BVM takes this out of the crash category for the short-term.

I would probably set up the cric kit (praying to god I don't have to use it), and have a combitube and set of ET tubes ready (probably one size smaller than usual to account for scarring from possible previous trach).

Assuming I was confident I could get the tube--something I'm not sure I could judge without looking at him, seeing his teeth, neck, etc--I'd do an RSI with etomidate and sux, try the BURP maneuver and have another person there hold the best position I got, and use the bougie.

If I failed and my partner failed, I know that with some effort I should be able to get the sats back up with BVM and a lot of effort. I'd only cric if sats kept going down with BVM after failing to get the tube, and the King or another airway adjunct didn't work.

That doesn't make this the right answer, though. If I looked at the guy, and thought, "no way in hell am I getting that one," and my partner likewise wasn't confident, I'd bag with 2 nasal airways (and an oral airway if tolerated) to the local hospital, and try to stabilize there before flying them out.

You know the patient needs a secured airway eventually, but your duty to the patient is to get them to definitive care alive. I wouldn't sacrifice the latter for the former, even if my ego takes a hit from not getting a difficult tube.

I'm curious now what you guys did. Can you fill us in, Paseo?

 

[Paseo Del Norte]

Sorry about the delay, I've been on shift and iPhoning it for internet access.

So, this is how it turned out. The paramedic team member expressed confidence in their ability to intubate in spite of many indicators of both a difficult airway and a potential difficult surgical airway.

A double backup consisting of a combitube and a cric kit was set up and the patient prepped and positioned for RSI. Etomidate and sux were administered per protocol. Upon laryngoscopy attempt number one, foreign matter was located in the posterior pharynx (large gob of what appeared to be mucus) and suction was initiated. No other structures were identified. The patient desaturated (upper 80's) several seconds into the attempt. The attempt was aborted and mask ventilation with positioning, adjuncts, cric pressure, and three person technique was immediately resumed. The providers were unable to effectively ventilate or oxygenate and the patient continued to desaturate, (pulse oximetry-78%).

A failed airway was called and a combitube was placed with primary esophageal placement and confirmation utilising sounds, capnography, and chest rise and fall. Utilising the combitube, the team was only able to increase saturations to 85-86%.

What do you think?

 

[Altruist]

What do you think?

A friend of mine said EMS is like carpentry: A lot of it is knowing how to fix your mistakes. In retrospect, trying for the tube was a mistake. Would I have done it? I'd like to think not, but given the lack of great alternatives here, I probably would have tried once and then used a backup, as this medic did. The RSA protocol others mentioned makes a lot of sense to me in this situation.

I guess you could argue that they at least took the patient out of the "immediate brain damage" level of de-oxygenation after the failed airway, and who knows how long they could have kept it at 94% like they were doing before the attempt anyway...

I might still have tried a hail mary with the bougie during the DL--with a Grade III Mallampati, a good BURP maneuver should let you see the back of the glottis--but with the de-satting and the mucus, I respect the decision to get out and start bagging.

I don't think there's a simple answer for this situation. I think you could argue that the medic shouldn't have tried, but I'd also argue that little harm came to the patient from the attempt, depending on the length of the desaturation. The medic probably didn't have much alternative to trying to secure the airway, and he/she had enough sense to leave it at one attempt, which I appreciate. A lot more harm comes from those cases where providers try and try and try, and the sats go down, down, down...

 

[Paseo Del Norte]

It is a tough situation being so far from a health care facility. It is reasonable to question going down the route of RSI. What alternatives could be considered? Possibly, bagging all the way to facility by ground EMS would have been a good consideration? Would modalities other than RSI such as nasal intubation be on the list for consideration?

Is there anything that can be done to help the current situation?

 

[canjosh]

Well, the sux removed whatever muscle tone was left, rendering masking ineffective.

I think we've covered all of the appropriate field modalities for airway management in this patient. Wouldn't have considered nasal intubation in this patient, although awake nasal with spontaneous respirations is pretty darn slick.

To help the current situation, if he's bucking, give sedation/rocuronium. If not bucking...suctioning, positioning are the next steps to try to improve oxygenation in my opinion.

Good case to discuss!

csmmedic:
Why roc?

 

[traumasurg]

Very interesting case. I would love to see more of these in the ems section.

 

[Dwindlin]

Very interesting case. I would love to see more of these in the ems section.

Couldn't agree more.

And I guess my contribution:

I think (with the presented information) I too would have attempted a more secure airway. Either transport modality is less than ideal with this patient, and I think both would make BLS airway management difficult. Without seeing the patient I don't know that I would have attempted ETI, however I think anything would have been better than simply leaving it at simple adjunct and BVM given the transport options available.

 

[traumasurg]

I wish I had more to contribute to this thread but being a basic you know what my options would be......

 

[proman]

however I think anything would have been better than simply leaving it at simple adjunct and BVM given the transport options available.

I think this thread illustrates why many physicians don't think paralytics belong in the field. I say this as an anesthesiology resident at the end of my generalist training, and a former paramedic (in Atlanta 911 system) for 5 years.

The OP describes someone that you know will be difficult to intubate, but currently ventilating (poorly). The last thing you want to do is remove that ventilation. The right answer is to assist ventilation (as shown in the case to be effective). And, I would say, go by ground to the nearest hospital to secure the airway. If it takes 3 people to mask (should really take 2 at most), then you can take them in the truck. You could try a blind nasal intubation, but I would hesitate since the patient is lying flat and blood can a disaster. Alternatively, you can try 1 intubation attempt without any drugs. When I encounter these types of patients in the hospital for an intubation, the first question I answer is whether or not they are somnolent enough to tolerate an awake DL.

By giving an induction agent and paralytics, you absolutely must secure the airway. Supraglottic devices (LMA, Combitube, King, whatever), are reliable but not 100%. Trust me, I've been in the situation where I pushed a paralytic, lost the ability to mask ventilate and the LMA didn't work. I'm sure the patients looked very similar.

This is a perfect case of "less is more". Support ventilation and oxygenation with BVM, go to nearest hospital by ground and alert them of a difficult airway. Just my input.

 

[Paseo Del Norte]

Good discussion. Sometimes the enemy of good is better. Pushing for a "better" intervention can be met with disastrous results.

So, the flight crew decided to place a naso-gastric tube down port #2 of the combitube and achieved gastric intubation. Gastric decompression with air and about 1,000 ml of gastric content was suctioned. Following the procedure, bag compliance increased significantly and the patient's saturations increased to 98%. The patient was transported to the closest hospital and a definitive airway was placed upon arrival. The patient was eventually discharged with the diagnosis of poly substance drug overdose and suicide attempt.

I am glad some people found the discussion helpful and/or worth while.

 

[Dwindlin]

I think this thread illustrates why many physicians don't think paralytics belong in the field. I say this as an anesthesiology resident at the end of my generalist training, and a former paramedic (in Atlanta 911 system) for 5 years.

The OP describes someone that you know will be difficult to intubate, but currently ventilating (poorly). The last thing you want to do is remove that ventilation. The right answer is to assist ventilation (as shown in the case to be effective). And, I would say, go by ground to the nearest hospital to secure the airway. If it takes 3 people to mask (should really take 2 at most), then you can take them in the truck. You could try a blind nasal intubation, but I would hesitate since the patient is lying flat and blood can a disaster. Alternatively, you can try 1 intubation attempt without any drugs. When I encounter these types of patients in the hospital for an intubation, the first question I answer is whether or not they are somnolent enough to tolerate an awake DL.

By giving an induction agent and paralytics, you absolutely must secure the airway. Supraglottic devices (LMA, Combitube, King, whatever), are reliable but not 100%. Trust me, I've been in the situation where I pushed a paralytic, lost the ability to mask ventilate and the LMA didn't work. I'm sure the patients looked very similar.

This is a perfect case of "less is more". Support ventilation and oxygenation with BVM, go to nearest hospital by ground and alert them of a difficult airway. Just my input.

I actually agree about paralytics, I wasn't suggesting attempting RSI. But why not place a supraglotic and see how that does instead of simply leaving adjunct/BVM (which sounds like the route they went)? Even with a rescue airway you've made it so now you only need 1 person to maintain ventilation and the airway is no less protected than with just the adjunct/BVM. If my post seemed to push for intubation then that's my bad, it wasn't supposed to, from the sounds of it I don't think I would have even tried (although that's really hard to say without actually seeing the patient).

 

[howelljolly]

Never heard it called a BURP maneuver. I always called it holding your own cric.

Anyone ever try the Pick (sp?) Method? Instead of handing off the cric pressure to an assistant, have them hold the laryngoscope once you position it. Then you control the cric pressure and the ET tube. I learned it in PHTLS and have seen it done once.

 

[Paseo Del Norte]

Never heard it called a BURP maneuver. I always called it holding your own cric.

Anyone ever try the Pick (sp?) Method? Instead of handing off the cric pressure to an assistant, have them hold the laryngoscope once you position it. Then you control the cric pressure and the ET tube. I learned it in PHTLS and have seen it done once.

Remember, BURP & ELM are not the same as cricoid pressure. Cric. pressure involves using pressure on the cricoid cartilage to occlude the esophagus and potentially decrease the passive aspiration risk.

BURP & ELM involve manipulation of the thyroid cartilage in order to potentially improve the glottic view. In fact, some sources suggest cricoid pressure may worsen the glottic view.

 

[proman]

I actually agree about paralytics, I wasn't suggesting attempting RSI. But why not place a supraglotic

The gag makes supraglottic airways difficult. There's really no difference between a supraglottic airway like an LMA and BVM except for the number of people involved, like you've mentioned.

What's also hurting is laying an morbidly obese patient flat. I know the EMTs placed a backboard, and most everyone considers it sacrilege to remove a backboard once placed (no matter how weak the indication). But at least tilting the torso up would have helped.

 

[proman]

Never heard it called a BURP maneuver. I always called it holding your own cric.

Anyone ever try the Pick (sp?) Method? Instead of handing off the cric pressure to an assistant, have them hold the laryngoscope once you position it. Then you control the cric pressure and the ET tube. I learned it in PHTLS and have seen it done once.

Sounds like a recipe to break teeth. Find your view with your right hand, tell your assistant to hold it there and put the tube in. BURP stands for backwards-upwards-rightwards pressure. It was first described in EM literature.

 

[wook]

I wish I had more to contribute to this thread but being a basic you know what my options would be......

Basics get lots of interesting calls!! You just may not be able to use all the cool tools.



Wook

 

[traumasurg]

Basics get lots of interesting calls!! You just may not be able to use all the cool tools.



Wook

It's so difficult because sometimes our truck is als and sometimes bls. The tools stay on and if it were not for that whole lose my license, lose my hopeful career in medicine I might be tempted to play with them.

 

[leviathan]

It's so difficult because sometimes our truck is als and sometimes bls. The tools stay on and if it were not for that whole lose my license, lose my hopeful career in medicine I might be tempted to play with them.

In most cases you give trauma patients better outcomes than ALS anyway, because they love to sit around and waste time playing with tools on scene.

 

[Paseo Del Norte]

In most cases you give trauma patients better outcomes than ALS anyway, because they love to sit around and waste time playing with tools on scene.

I read a few papers some years back comparing outcomes of patients with similar types of trauma. A comparison between patients with similar injury types who were transported by EMS versus those who were transported by homeboy ambulance service was created.

Outcomes were better in the homeboy groups. Access and time to definitive care appeared to be a potential factor in the findings. While I do not think the papers I remember made definitive statements, the notion that perhaps we waste too much time performing procedures on scene is valid IMHO.

 

[Altruist]

Outcomes were better in the homeboy groups. Access and time to definitive care appeared to be a potential factor in the findings. While I do not think the papers I remember made definitive statements, the notion that perhaps we waste too much time performing procedures on scene is valid IMHO.

Definitely true, although most services are pushing to get away from this with their protocols. The surgeons at the hospital I was based out of were suggesting we even manage airways en route, which might have been a step too far; but definitely I wouldn't worry about an IV until I was en route in normal trauma situations.

I think another consideration with amateur ambulance services is that, depending on the system, there may be a delay while PD secures the scene before EMS gets to the patient, in addition to the delay of someone calling 911 and everyone responding. If minutes count, the homeboy advantage quickly adds up.

 

[Dwindlin]

Definitely true, although most services are pushing to get away from this with their protocols. The surgeons at the hospital I was based out of were suggesting we even manage airways en route, which might have been a step too far; but definitely I wouldn't worry about an IV until I was en route in normal trauma situations.

I think another consideration with amateur ambulance services is that, depending on the system, there may be a delay while PD secures the scene before EMS gets to the patient, in addition to the delay of someone calling 911 and everyone responding. If minutes count, the homeboy advantage quickly adds up.

I did my best to do everything en-route, including definitive airway management. Typically only thing that was done on scene was initial airway management (so simple adjunct and BVM basically), immobilization and my quick 30 seconds head-to-toe (done while immobilizing). Tried my best to only violate this in cases of entrapment or other unavoidable scene delays. Did it always happen? Of course not, but I definitely think it is doable most times.

As an aside I had access to wave-form capnography, so I had a very solid way to confirm tube placement while moving.

 

[orderly]

This is very interesting reading guys. While I dont understand exactly how all the procedures work, I like the discussion about timing and the logistics and of course the most suitable treatment plans.

I think this kind of debate is actually very important too, as it allows those of us who are (or want to be in my case) Paramedics to learn and perhaps realise better practice when it comes to situations. Anyway, its better to learn it here where you have room for error than in the field!