BLS and Combitube

[DesertMedic66]

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.

Our protocols say that once a combitube is placed it will not be removed. We only use combitubes if the medic is unable to intubate. So if a combitube is already in place when the medic gets there it will not be removed.

 

[8jimi8]

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?

Consider a combitube / rescue airway / supraglottic airway device after prolonged bvm ventilations/ poor quality bvm compliance.

gently bagging /c excellent technique and optimal patient positioning will carry you a very long way without accidently traumatizing the trachea in the worst case scenario of orotracheal placement of combitube.

 

[sirengirl]

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.

^^This is my choice exactly, IF this vv is the case.

gently bagging /c excellent technique and optimal patient positioning will carry you a very long way without accidently traumatizing the trachea in the worst case scenario of orotracheal placement of combitube.

As it's been said on here before by another, it's always case-by-case, but if I am getting good chestrise/bilat breath sounds and pink skintone from bvm and ALS is < 10mins, I see no reason to use a combi. Just another gray area of EMS

 

[Chimpie]

Just another gray area of EMS

As long as that gray matter isn't brains...

 

[sirengirl]

As long as that gray matter isn't brains...

This!
There should be an option to +1 people's posts...

 

[usalsfyre]

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

First line cardiac arrest treatment here. We have the option of pulling the King and placing a ETT if we feel it's warranted. Can't say I feel that it often is, The King does a superb of managing 95% of airways in arrest, and it does it more quickly with no need (or temptation) to interrupt compressions to place it. Typically, if first responders or bystanders are available I'll have them continue compressions, my Basic partner place a King while I establish an IO and then continue the code.

While an ETT is preferred in most cases, the relegation of alternative airways to "back up only" status is a lack of foresight and old medicine in most cases. There's times when placing an ETT is not practical. If you want to see an example of preemptive use of alternative airways look up Dr. Darren Braude's Rapid Sequence Airway.

 

[flyfisher151]

Thanks!

 

[usafmedic45]

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

It's not new at all and for glucose at least, there's a fair amount of evidence that it's not all that an effective route.

 

[feldy]

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!

unconscious person...yes. Code...if only BLS is on scene awaiting ALS then check it as long as CPR is not interrupted. If ALS gets on scene then while they are starting to push their meds then check it to see if any other hypo/hyperglycemic meds are necessary.

 

[Shishkabob]

How far away help is hardly ever changes what I do... if it needs to be done it gets done. If you need an advanced airway, get one in, even if the Paramedics are walking in the door as you're pulling it out of the packaging.



My EMT and I have talked about our plans for codes, and have a system worked out. If we get an arrest and someone is doing CPR, his first job is to insert a King, while I do other ALS stuff. If he can't get the King, or something precludes its use, that's when I go for the ETT. In the past 5 arrests we've had, I've only had to intubate once, and that's because he couldn't get the King past the giant tongue.

 

[Shishkabob]

Arrest? Not checking the BGL obv

Why aren't you checking BGL on an arrest?

 

[rwik123]

Why aren't you checking BGL on an arrest?

It's just not something I see around me at least at the BLS level. If I were ALS and was starting a line and already had blood, why not. It's pretty low on the importance scale in my opinion. How many arrests have you seen that have been the result of a glycemic emergency? Maybe its something I should be doing.

 

[usalsfyre]

How many arrests have you seen that have been the result of a glycemic emergency? Maybe its something I should be doing.

Not very many but it does happen and is an easily reversible cause. If nothing else you should be checking so that once paramedics arrive they can provide the correct treatment.

 

[feldy]

even as a basic...i see checking BGL as part of gather vitals. s/s of a glycemic emergency are similar to so many medical/ traumatic emergencies that it is something that you would want to rule out.

Since i tend to work nights i get a lot of ETOH pts so that is also my justification for obtaining BGL to make sure they are indeed ETOH and not low or high

 

[rwik123]

even as a basic...i see checking BGL as part of gather vitals. s/s of a glycemic emergency are similar to so many medical/ traumatic emergencies that it is something that you would want to rule out.

Since i tend to work nights i get a lot of ETOH pts so that is also my justification for obtaining BGL to make sure they are indeed ETOH and not low or high

Yeah totally a vital. Im just saying it's not high up on my priorities if working a code. But if time allows, I'll be sure to do it from now on.

 

[Shishkabob]

Honestly as a basic on an arrest, there's only so much you can do in the first place. If someone is bagging and someone is doing compressions... all the major BLS things are out of the way and taken care of.

Heck, even the person who's bagging has time to check a BGL in between breaths (if you're doing the AHAs 30:2)

 

[feldy]

Honestly as a basic on an arrest, there's only so much you can do in the first place. If someone is bagging and someone is doing compressions... all the major BLS things are out of the way and taken care of.

Heck, even the person who's bagging has time to check a BGL in between breaths (if you're doing the AHAs 30:2)

unless you are using a resQpod or other similar device

 

[usalsfyre]

unless you are using a resQpod or other similar device

ResQPod's science is starting to look suspect anyway....

 

[Smash]

ResQPod's science is starting to look suspect anyway....

What's that? An expensive piece of plastic pushed on services by a manufacturer may not be all it cracked up to be? Say it ain't so!! 

 

[DesertMedic66]

Honestly as a basic on an arrest, there's only so much you can do in the first place. If someone is bagging and someone is doing compressions... all the major BLS things are out of the way and taken care of.

Heck, even the person who's bagging has time to check a BGL in between breaths (if you're doing the AHAs 30:2)

Can't check BGL (in my county). Our BLS rigs don't carry the meter because it's not in our scope <_<