No RSI- Teeth clenched from Head Injury-WWYD

[EMS Patient Care Advocate]

The Short of it.
Motor vehicle crash, pt unresponsive, teeth clenched.
In ambulance unable to pass any oral airways, NPA placed. Assisted ventilations, patient respirations are 6 a minute without assistance. Opt not to attempt nasal intubation due to likely complications and increased ICP.
No chest or lung injuries
Pupils unequal
Pt has heavy scarring over veins from what is likely heavy long term IV drug use
This state does not carry RSI medication pre-hospital.
The state does not allow facilitated intubation if you want to keep your license.
You invited air medical with the RSI supplies and protocols. They are not on scene yet.
Respirations difficult to deliver with clenched teeth.
Constant suction of blood and secretions in airway.
Looking at the big picture, knowing the respirations may be depressed from head injury or drugs- I need the patient to help me help him breath. I pull out the Narcan and slowly titrate and to my not so big surprise- RR came up to about 20 a minute. SP02 improved to 100% just gentle BVM assistance.
Just prior to air medical paralyzing the patient he begins decorticate posturing.
What would you have done?

 

[LondonMedic]

Nothing different. Although, if I was ventilating and oxygenating well I might have been tempted to hold off naloxone. By giving it, although it sounds like you were sensible about it, you risk making them agitated and you risk making them vomit - both of which could ruin their day.

 

[EMS Patient Care Advocate]

Nothing different. Although, if I was ventilating and oxygenating well I might have been tempted to hold off naloxone. By giving it, although it sounds like you were sensible about it, you risk making them agitated and you risk making them vomit - both of which could ruin their day.

something I was weighing heavy in my mind as I have had more problems with Narcan than anything. But it did help patient RR improve and increase oxygenation when I needed it most. I had no way of securing his airway but to have him help me, any other ideas?

 

[fast65]

I would have done the same thing, just titrate it enough to improve his respirations, which it sounds like you did. The only other option at this point is to cric him. I mean, no RSI, nasal intubation contraindicated, and inadequate ventilations with the clenched teeth all seem like the ingredients for a cric to me.

 

[EMS Patient Care Advocate]

I would have done the same thing, just titrate it enough to improve his respirations, which it sounds like you did. The only other option at this point is to cric him. I mean, no RSI, nasal intubation contraindicated, and inadequate ventilations with the clenched teeth all seem like the ingredients for a cric to me.

If there was much more trouble ventilating there would have been no choice. I just thought it weird to have two near cric scenarios in my first two years as a medic. The first I finally cleared the chicken from her trachea, and this one. Its a pucker factor until I can get air medical on scene in this state for the proper medications to intubate. Thank you for you time and interest.

 

[fast65]

If there was much more trouble ventilating there would have been no choice. I just thought it weird to have two near cric scenarios in my first two years as a medic. The first I finally cleared the chicken from her trachea, and this one. Its a pucker factor until I can get air medical on scene in this state for the proper medications to intubate. Thank you for you time and interest.

Yeah, that is kind of odd, but when you think about it, it's all about chance. Hell, I could have three patients that need a cric tomorrow, or I could have none, it's all left up to chance. The important thing is that you're searching for feedback on your calls and that says that you care about improving yourself and your abilities.

 

[EMS Patient Care Advocate]

Yeah, that is kind of odd, but when you think about it, it's all about chance. Hell, I could have three patients that need a cric tomorrow, or I could have none, it's all left up to chance. The important thing is that you're searching for feedback on your calls and that says that you care about improving yourself and your abilities.

im honored. Im gunna shoot out another one I think. Thanks this is exciting.

 

[Shishkabob]

I've had my fair share of patients needing RSI when I didn't have RSI available. I hated it. I now refuse to work for an agency that doesn't have RSI.

If flight was going to be any further, and bagging difficult with a failed airway, I agree, crich, either surgical or needle, would be the next move.

 

[EMS Patient Care Advocate]

Scary as the state this occured in I can do either needle or surgical airways. In the bordering state where I also work they have removed ALL surgical/needle airways OUT of the protocols. Also currently my system does not have the state requirment of capnography for intubated patients. So that paticular service I currently cannot intubate, cannot cric and do not have RSI. To boot we only carry one adult combi-tube as my back up. I dread going to work because of my fear that I will be standing over the statistical 1% of my patient that will die without a tube. Im acctually fearful im going to end up in court explaining why I breeched protocol just so I can sleep at night knowing I did my best to the level of my training. sorry little vent session there.

 

[Shishkabob]

Honestly it's retarded to not have cric available to Paramedics that have to maintain an airway.

It's stupid not to have intubation (looking at you, Dallas FD)

It's idiotic to not mandate capnography to confirm placement (though it can still mess up)


And RSI has been proven to be not only as successful, but as safe, when done by a properly educated EMS ground crew as it is in the hospital. (The issue is making them properly educated... some places don't care, and those places don't need access to RSI)

 

[EMS Patient Care Advocate]

Honestly it's retarded to not have cric available to Paramedics that have to maintain an airway.

It's stupid not to have intubation (looking at you, Dallas FD)

It's idiotic to not mandate capnography to confirm placement (though it can still mess up)


And RSI has been proven to be not only as successful, but as safe, when done by a properly educated EMS ground crew as it is in the hospital. (The issue is making them properly educated... some places don't care, and those places don't need access to RSI)

I fully agree!!

 

[usafmedic45]

The Short of it.
Motor vehicle crash, pt unresponsive, teeth clenched.
In ambulance unable to pass any oral airways, NPA placed. Assisted ventilations, patient respirations are 6 a minute without assistance. Opt not to attempt nasal intubation due to likely complications and increased ICP.
No chest or lung injuries
Pupils unequal
Pt has heavy scarring over veins from what is likely heavy long term IV drug use
This state does not carry RSI medication pre-hospital.
The state does not allow facilitated intubation if you want to keep your license.
You invited air medical with the RSI supplies and protocols. They are not on scene yet.
Respirations difficult to deliver with clenched teeth.
Constant suction of blood and secretions in airway.
Looking at the big picture, knowing the respirations may be depressed from head injury or drugs- I need the patient to help me help him breath. I pull out the Narcan and slowly titrate and to my not so big surprise- RR came up to about 20 a minute. SP02 improved to 100% just gentle BVM assistance.
Just prior to air medical paralyzing the patient he begins decorticate posturing.
What would you have done?

Crike.

 

[Akulahawk]

What would you have done, OP, if the Narcan didn't work? (I tend to agree with usafmedic45 on this, btw)

What would really be horrible would be to have that trismus patient and you can't do NTI, you can't cric, you don't have RSI or Facilitated Intubation... and the Narcan doesn't work or isn't indicated. OP: you nearly had that patient!

When that happens, you just do the best you can, get the "right" resources mobilized that can do that stuff and if they're unavailable. PUHA.

 

[EMS Patient Care Advocate]

What would you have done, OP, if the Narcan didn't work? (I tend to agree with usafmedic45 on this, btw)

What would really be horrible would be to have that trismus patient and you can't do NTI, you can't cric, you don't have RSI or Facilitated Intubation... and the Narcan doesn't work or isn't indicated. OP: you nearly had that patient!

When that happens, you just do the best you can, get the "right" resources mobilized that can do that stuff and if they're unavailable. PUHA.

Well if narcan didnt work, And BVM continue to get more difficult, and I couldnt get bird to me when I did, yes I would have been cutting. I guess I didnt realize I was literally one/two decisions away, WOW.
when the patient started to posture I did try calling online med control to request "head injury patient safety sedation" I dont have a spacific protocol for it in this state, but I do in others- but I could defend that I dont want my patient to cause further harm to himself and the sedation may prevent further spinal comprimise. Also I understand by sedating the patient I may make my ventilation/oxygenation nightmare worse.
However the only thing that doc seemed to hear was narcan, and combative. So when I requested sedation I started getting the "what are you an idot" voice over the radio. I heard lifeflight overhead and discontinued the doc conversation as I was going to get no where and had what I needed, an RSI team.
Thoughts?

 

[usafmedic45]

Well if narcan didnt work, And BVM continue to get more difficult, and I couldnt get bird to me when I did, yes I would have been cutting.

So you're willing to wait around to see if the helicopter can beat hypoxia to the scene?

 

[EMS Patient Care Advocate]

So you're willing to wait around to see if the helicopter can beat hypoxia to the scene?

Nope not willing. Hopeful !

 

[usafmedic45]

No offense, but that's just about the most moronic thing I have ever heard. Yeah, you're a true patient care advocate if your line of thinking is that skewed. Do the crike and worry about getting the patient to the hospital after you have an airway. A helicopter is a transportation modality, not a treatment option. Calling for the helicopter should be a tougher decision than performing a surgical airway of which the hardest part is simply picking up the scalpel.

 

[EMS Patient Care Advocate]

No offense, but that's just about the most moronic thing I have ever heard. Yeah, you're a true patient care advocate if your line of thinking is that skewed. Do the crike and worry about getting the patient to the hospital after you have an airway. A helicopter is a transportation modality, not a treatment option. Calling for the helicopter should be a tougher decision than performing a surgical airway of which the hardest part is simply picking up the scalpel.

Yes I always advocate what is in the patients best interest. Dont be so quick to throw such words, yes I do take offense to that. Since you dont know the whole story let me include some things you dont know about the scene. Its 45 min from the nearest level 2 hospital. Its 2 hours by ground. Its 15 min by air. I did NOT wait on a scene for anything. I transported to a location in the direction of the hospital intercepting with a helicopter. Im glad you are so excited to cut someones throat just because a protocol says you can. Use ALL your tools. I had obtained a fully oxygenated patient without cutting his neck. Im ok knowing what I did. And im ok knowing you would have slit his throat. Be nice, you sound smarter.

 

[usafmedic45]

I had obtained a fully oxygenated patient without cutting his neck.

Yeah, and congratulations, but you could have more optimally secured the airway. A "fully oxygenated" patient is not the only issue at hand in the ventilation of head trauma and without the ability to monitor ETCO2 you may be have contributed unintentionally to the downward spiral through your efforts to obtain a 'perfect score' saturation. If he was in the condition you state, you need to secure the airway, not simply obtain one.

Since you dont know the whole story let me include some things you dont know about the scene. Its 45 min from the nearest level 2 hospital. Its 2 hours by ground. Its 15 min by air.

Once they get to the scene, do what they need to do and then take off again, then it's fifteen minutes to the hospital. Let's not forget to factor in all of the other time constraints that tend to lead to HEMS not being as expedient as people like to believe. It's four to six minutes to hypoxic encephalopathy. Can you intercept with a helicopter that quickly?

Im glad you are so excited to cut someones throat just because a protocol says you can.

I'm not eager but when the option is "brain injury or death" versus a surgical airway, then I do not hesitate and worry about calling for a helicopter before handling step one of any protocol.

Be nice, you sound smarter.

Think your stance all the way through before posting, it tends to have the same effect.

 

[EMS Patient Care Advocate]

okay, reboot. I didnt feel the patient was currently suffering from any hypoxia after the narcan, though I didnt have an airway secured like I would have preferred. Maybe next time Ill cut, maybe not. I did my best to give him optimal care and recovery, we dont KNOW I contributed to injury, but I think I saved him from further brain injury due to hypoxia, maybe not- another thing is like you say I didnt have capnography. I AM here to learn! I dont like to be insulted when trying so hard and peoples lives are at stake- You saying that I make moronic decisions made me defensive for obvious reasons. If I was accross the boarder protocol does not allow for any needle or surgical airways. I felt if I didnt get a positive response from my current interventions then I would have had to get more agressive. I was using cric as a last resort, maybe I shouldnt hesitate because I AM better than that. Knowing in the back of my mind I was then going to be ONE of a small handfull of medics in this state to EVER need to do one. Dont leave out that Im no pro at expressing myself over a computer in writing. I think you must have taken my comment for being hopeful for additional care such as Helicopter with RSI to prevent the need for surgical intervention as me sitting and waiting. I didnt feel like I did this, but maybe I did? What if there was no helicopter available, you bet my thinking would have changed. But the wait isnt what you think since I requested the helicopter on arrival. By the time the patient was extricated and transported there was a rather seemless transition I thought?