BLS and Combitube

[sirengirl]

So recently I was sitting at my volunteer BLS station talking to another EMT. I'll mention early on that I'm the youngest EMT and the youngest volunteer at the station, as the city it's in is a small, predominantly elderly city, and it's not unusual for people at the station to be old enough to be my grandparents, and so to treat me condescendingly. I'm used to it. This particular EMT-B was having a discussion with me about "what would you do if..." which is how we wear away the time waiting for someone to slip and fall at a nursing home or something. Our discussion at the time was about Combitubes. He was asking when I would decide to insert one versus use a BVM. The county that we are in is ALS Fire/Medic and we're the only BLS unit around; the city is also about five square miles and very small. Our station is half a mile from the closest fire station.

"Well," I told him, "I'd consider a combitube if they're unresponsive, cardiac, and ALS is more than 10 mins ETA, because that's long enough to get a few rounds of CPR in and a shock or two if indicated."

He begins to argue with me about how do you know how far away they are because apparently he thinks calling and asking for an ETA is a hard thing. Ever since, I've been wondering what others would do. Of course I could bag someone until the cows came home if I so desired, so in all technicalities unless our rescue is coming from the next town up (a 20 minute Interstate drive), I probably wouldn't consider a combitube unless they're getting hypoxic in front of me. I was wondering what others think, from a BLS standpoint?

 

[TransportJockey]

When I work a code here... CPR is first priority. Then I'll toss a combitube even if my medic is walking through the door. An airway is an airway, and in a code, fast and not interrupting chest compressions is goal 1.
After combi, I start looking for lines, usually staying at the head after placing the combi and sticking an EJ

 

[sirengirl]

Exactly. I'm more concerned with doing adequate compressions than I am about monkeying around with a fancier airway (assuming that I am having no complications with a BVM OPA/NPA) when I know the medics are going to rip it out when they get there and intubate. I've never had an occasion thusfar that, should it have been a code, I was on scene long enough to be able to get in a full round of compressions before ALS arrival. They usually pull up within 2 minutes.

 

[TransportJockey]

I work an ILS truck (as sr on truck) in a rural county. We usually have maybe 2 medics on duty in county at any given time. If I have a combi in place when they arrive, they usually go with that and don't yank it to intubate. If you have a medic that will pull a perfectly patent rescue airway just so they can drop an ETT in a code, they need to be kicked down a notch or two and told to leave their ego at the door. With the new guidelines, compressions are so much more important than airway.

 

[sirengirl]

I won't say much about the medics I've worked with from that particular station other than that, there are a few who could stand to work on their people skills and their egos. I've never had an opportunity to see them do more than a 12-lead. I'm sure they do great work, but what exactly, remains to be seen... In any case my initial question was whether you would bother with a combi if you know ALS is within 10 minutes and you have a patent airway with OPA/NPA.

 

[TransportJockey]

Sorry, didn't mean to pull it off topic. But yea, my answer would be yes in codes. Other circumstances would be maybe

 

[abckidsmom]

Exactly. I'm more concerned with doing adequate compressions than I am about monkeying around with a fancier airway (assuming that I am having no complications with a BVM OPA/NPA) when I know the medics are going to rip it out when they get there and intubate. I've never had an occasion thusfar that, should it have been a code, I was on scene long enough to be able to get in a full round of compressions before ALS arrival. They usually pull up within 2 minutes.

I work an ILS truck (as sr on truck) in a rural county. We usually have maybe 2 medics on duty in county at any given time. If I have a combi in place when they arrive, they usually go with that and don't yank it to intubate. If you have a medic that will pull a perfectly patent rescue airway just so they can drop an ETT in a code, they need to be kicked down a notch or two and told to leave their ego at the door. With the new guidelines, compressions are so much more important than airway.

Absolutely. I think that universally, a good medic will not pull a functional combitube in order to intubate. That assumes good lung sounds, expected EtCO2 waveform (flat if dead), and good compliance.

Pulling a combitube invites laryngeal edema to take over and block whatever airway you had left. I saw a few CBT switchovers to ETTs while I worked in an ICU, and it was always a well-choreographed routine, not just a simple pull the tube and intubate kind of deal.

You're on the right track. Keep it up. And it's super easy to get an ETA from incoming units. "What's your ETA?" "12 minutes." Done. The most complicated part might be if they state their location instead of a time. Then you have to think a little. Oh, well.

 

[abckidsmom]

I won't say much about the medics I've worked with from that particular station other than that, there are a few who could stand to work on their people skills and their egos. I've never had an opportunity to see them do more than a 12-lead. I'm sure they do great work, but what exactly, remains to be seen... In any case my initial question was whether you would bother with a combi if you know ALS is within 10 minutes and you have a patent airway with OPA/NPA.

Sorry, I hijacked, too.

Patent airway with OPA/NPA? That depends on how much air is getting into their stomach, and how long it's going to be until they puke. It's tough I know, but it's case-by-case. Cardiac arrest? Don't interrupt CPR, go ahead and drop the CBT. Unconscious? Wait a bit, figure out why the patient's unconscious. Unconscious diabetic? Probably not. Seizure? Probably not. Other etiologies will vary.

If you are NOT putting in a CBT and are waiting on scene for ALS, you definitely MUST have portable suction out and ready, even ON, waiting for the emesis.

 

[sirengirl]

And it's super easy to get an ETA from incoming units. "What's your ETA?" "12 minutes." Done. The most complicated part might be if they state their location instead of a time. Then you have to think a little. Oh, well.

Yeah the guy I was talking to was making it sound as though it was an ordeal to have to contact dispatch (ours is separate) and ask them to have the responding unit tell their ETA and then let me know...

 

[sirengirl]

It's tough I know, but it's case-by-case.

THIS. I live by this rule. When I was still precepting onto the squad I worked with an EMT who, whenever we got a call, wanted me to get out of the truck, stop in front of her before entering the building, and verbalize a complete list of exactly what I was going to do and what I thought about the call before ever seeing the patient. The end of that day couldn't come fast enough....

 

[Smash]

Absolutely. I think that universally, a good medic will not pull a functional combitube in order to intubate. That assumes good lung sounds, expected EtCO2 waveform (flat if dead), and good compliance.

Sorry, another hijack. EtCO2 waveform will not be flat unless you are trying to resuscitate a corpse. If it is an actual, viable arrest and good quality CPR is being performed then you will have a waveform. The actual etco2 itself may be low, but the waveform will still be there.
If you don't have a waveform, something is wrong that needs fixed, like rube in wrong hole, obstructed tube, that sort of thing.

 

[marcus2011]

If adequate ventilation is being done with a combi or a king with bilateral chest rise then by all means leave the BIAD in place. Taking the time to remove the tube when the medics get there to drop a ET tube could be used in better things like getting an iv set up, switching monitors if yours does not have a Manuel shock or other things like that

 

[abckidsmom]

Sorry, another hijack. EtCO2 waveform will not be flat unless you are trying to resuscitate a corpse. If it is an actual, viable arrest and good quality CPR is being performed then you will have a waveform. The actual etco2 itself may be low, but the waveform will still be there.
If you don't have a waveform, something is wrong that needs fixed, like rube in wrong hole, obstructed tube, that sort of thing.

You're right. I misspoke. I was picturing a very flat, low waveform. I know waht you're talking about. Thanks for clarifying my words.

 

[flyfisher151]

Good thread! Got my mind turning. I see why no on seizures and diabetic emergencies. BTW?? Do you check BGL on an unconscious person to determine diabetic emergency??? I'm a humble student and yes I am asking this question for real trying to learn. Or do you try to obtain this info from a famliy member during your SAMPLE history? Bracelet/Necklace? Thanks in advance. I figure admitting you know nothing will help facilitate the learning process!

 

[Anjel]

Ok....what I would do lol

If it is an arrest. and I am going to be transporting by myself...then they are getting a combitube. Im not gonna mess around trying to get a seal with a mask.

I can place the tube in less than 30 seconds. Once its ready. So not a problem.

However... If medics are gonna be there in less than 10 minutes. And I have someone helping me with cpr then no I probably wouldn't use it.

So.... 2 person cpr medics coming....probably not

By myself...heck yea I am. Ill have a cop or ff open the package and fill my syringes or do what I gotta do while they do compressions ( if they are trained to and can)

 

[babygirl2882]

In my dept 99.9% there will be ALS on scene, we rarely rarely just have a BLS crew, but I know of at least one medic that if he can't get an ETT will let me put in a combi.


Not to hijack the thread but, anyone out there use the king airway?

 

[rwik123]

Good thread! Got my mind turning. I see why no on seizures and diabetic emergencies. BTW?? Do you check BGL on an unconscious person to determine diabetic emergency??? I'm a humble student and yes I am asking this question for real trying to learn. Or do you try to obtain this info from a famliy member during your SAMPLE history? Bracelet/Necklace? Thanks in advance. I figure admitting you know nothing will help facilitate the learning process!

Arrest? Not checking the BGL obv

Unconscious... If it's within your scope (some basics can and can't check BGL). Youd find out from family members also. BUT as a basic there's no intervention you can do to combat a diabetic emergency if there unconscious. Remember for glucose the patient has to be conscious and able to take the glucose with a patent airway.

 

[bigbaldguy]

. Remember for glucose the patient has to be conscious and able to take the glucose with a patent airway.

I can think of one way a basic could administer glucose without a patent airway but I have to admit I feel kind of icky even thinking about it <_<

 

[rwik123]

I can think of one way a basic could administer glucose without a patent airway but I have to admit I feel kind of icky even thinking about it <_<

New protocol! Genius. It'll be a whole new thing, basics pushing meds up people's butts.

 

[bigbaldguy]

New protocol! Genius. It'll be a whole new thing, basics pushing meds up people's butts.

"hmmmm that pill is kinda big I don't think I'll be able to swallow it"

"oh not to worry it's not going in that end"