Intubation WITH gag reflex

MedicPatriot

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I have heard of this done before and I am wondering if people here have actually done it. I know a guy who has orally intubated a CHF patient that was actually conscious back in the day before CPAP as well as someone who has done that to an unconscious agonal breather with a gag reflex. We don't have RSI around here by the way, and don't ask why they didn't nasally intubate...because I don't know why.

I know it can't be good for the anatomy, especially in a head injured patient as it would increase ICP. I'm just wondering if anyone here has done it, or seen it, and how hard was it? I can't imagine its easy to do. In fact when I heard about it I was shocked, as it seems so barbaric.
 

EMSLaw

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Our medics have RSI if necessary, so no, I've never seen this done, or heard of it being done.

My understanding is that 'back in the day' as you say, before CPAP, nasal intubation was the go-to treatment for CHF patients. It has since fallen out of use, which is why only medics with older certifications are still permitted to do it here. If the patient was conscious, but had no gag reflex... I guess it would work, though it would involve a major protocol variation. I'll plead ignorance on that.

I can't say much about the second case, other than that I'd think agonal respiration wouldn't go along with a protective gag reflex.

The problem is not that it seems barbaric - medicine occasionally involves doing unpleasant things to patients (cardioversion comes to mind). But the patient will likely vomit if you trigger the gag reflex and that is: A) an aspiration risk and B) likely to result in my needing a new uniform and being covered in disgustingness.
 

18G

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I would never recommend orally intubating a patient with a gag reflex. If you really had to you could try lidocaine spray to back of throat to suppress the gag reflex. We're allowed to nasally intubate so never had that issue arise.
 
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MedicPatriot

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I would never recommend orally intubating a patient with a gag reflex. If you really had to you could try lidocaine spray to back of throat to suppress the gag reflex. We're allowed to nasally intubate so never had that issue arise.

We can nasally intubate too, thats the strange part
 

MSDeltaFlt

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I have heard of this done before and I am wondering if people here have actually done it. I know a guy who has orally intubated a CHF patient that was actually conscious back in the day before CPAP as well as someone who has done that to an unconscious agonal breather with a gag reflex. We don't have RSI around here by the way, and don't ask why they didn't nasally intubate...because I don't know why.

I know it can't be good for the anatomy, especially in a head injured patient as it would increase ICP. I'm just wondering if anyone here has done it, or seen it, and how hard was it? I can't imagine its easy to do. In fact when I heard about it I was shocked, as it seems so barbaric.

On the pt who was conscious with "an active gag reflex". What it a real gag? Or was the pt merely biting down on the blade? There is a difference.
 

medicsb

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I think it would be damn near impossible to do it on someone with a fully intact gag reflex. Twice on severely obtunded patients (both were overdoses) where when I scoped them, it was obvious that they had some gag reflex left, but it was weak, thus I was able to pass the tube.
 

Akulahawk

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CANMAN

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If you are to the point of considering a retrograde intubation then just pull the trigger on a surgical airway and be done with it....

Although CPAP is prob one of the best things to happen to EMS in the recent years, I miss nasal intubation :(
 
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NomadicMedic

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If you are to the point of considering a retrograde intubation then just pull the trigger on a surgical airway and be done with it....

Although CPAP is prob one of the best things to happen to EMS in the recent years, I miss nasal intubation :(

Yep, if you're making a hole, why use a wire? Just shove a tube in there! And we still have nasal intubation, although CPAP has nixed my last few nasal tube opportunities. :/ Agreed that CPAP, the EZ-IO and the LUCAS device are the three best EMS innovations in recent history.
 

rayzon20mg

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if the patient has a gag reflex for intubation here we can drop the patient with either scoline or dipravan and intubate.
 

medicsb

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Although CPAP is prob one of the best things to happen to EMS in the recent years, I miss nasal intubation :(

The same sentiment from many of the long timers I worked with. When I came on, we had CPAP and RSI, so I only once had an attempt (it failed) in 5 years. Every now and then one of the long timers would nasally intubate someone and everyone in the ED would swing by to have a look and word would spread to other medic units. I think that out of 800ish ETIs, only about 10-20 would be attempted nasally per year.
 

IrightI

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I have heard of this done before and I am wondering if people here have actually done it. I know a guy who has orally intubated a CHF patient that was actually conscious back in the day before CPAP as well as someone who has done that to an unconscious agonal breather with a gag reflex. We don't have RSI around here by the way, and don't ask why they didn't nasally intubate...because I don't know why.

I know it can't be good for the anatomy, especially in a head injured patient as it would increase ICP. I'm just wondering if anyone here has done it, or seen it, and how hard was it? I can't imagine its easy to do. In fact when I heard about it I was shocked, as it seems so barbaric.

The joys of having Succs and Etmoidate on the truck.

RSI for the Win!:cool:
 

usalsfyre

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The joys of having Succs and Etmoidate on the truck.

RSI for the Win!:cool:

For the win...up until you run into a 400 pounder with no neck who you can't get preoxygenated above the the high 80s and looks to be severely acidotic. What now?

RSI is an incredibly useful tool, but it's not a cureall.
 

IrightI

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For the win...up until you run into a 400 pounder with no neck who you can't get preoxygenated above the the high 80s and looks to be severely acidotic. What now?

RSI is an incredibly useful tool, but it's not a cureall.

Sounds like my regular pts :rofl: You say what now...and I say Cric. There is always a way, and just for kicks il have bicarb on standby.

The last thing you want is to paralyze someone, and have to bag them through the ER doors without having a tube. We make sure that never happens with our service. :cool:
 

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