Experience Matters in EMS Intubation

[docB]

This artical in the current Annals of EM from Wang et. al. sounds like it would shed some light on the questions surrounding EMS intubation. Sadly it does not. It does find that patients intubated by more experienced EMS providers do better.

Conclusion
Rescuer procedural experience is associated with improved patient survival after out-of-hospital tracheal intubation of cardiac arrest and medical nonarrest patients. Rescuer procedural experience is not associated with patient survival after out-of-hospital tracheal intubation of trauma nonarrest patients.

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[DitchDoc73]

This artical in the current Annals of EM from Wang et. al. sounds like it would shed some light on the questions surrounding EMS intubation. Sadly it does not. It does find that patients intubated by more experienced EMS providers do better.

The system I work in is starting to recommend bypassing ET intubation, and going directly to rapidly inserted BLS airways (King Tube, LMA, etc). Our QA/QI director states that our ROSC rates are higher with BLS airways than with ETI. I have heard rumors that our medical director is in the process of doing a study on the impact of airway choice, and I think it may be interesting to see what the results may be!

 

[malkboy]

The burning question in pre-hospital medicine is .whether .or not we should even be intubating in the field. I personally like to have the skill available in my arsenal, but have come to embrace supraglottic airways, particularly the king device. I believe the majority of pre-hospital intubations probably occur during cardiac arrests, but as DitchDoc73 pointed out, we are moving away from ETI towards supraglottic airways for their ease, rapid placement, and ability to focus on chest compressions. In 99% of OOHCA, I would not be intubating the patient. However, I still intubate other types of patients almost always using a pharmacologically assisted method. Although most paramedics that I work with have numerous intubations each year, I would venture to say that only the flight guys in my area have over 26, which is what the study defines as high (very high). We attempt to correct this lack of exposure by going to cadaver labs and having 2 mac, 2 miller, and 1 bougie manikin intubations every shift before we are able to sign out our narcotics. Additionally, we make intubation a team skill, where if the intubator fails, the whole team fails. No longer is there a case where 1 person is intubating and 1 person is starting an IV. When the laryngoscope is picked up, both people are focused on airway. The person intubating is required to call out landmarks as they see them (e.g. lips, teeth, tongue, uvula, arytenoid cartilage, cords...).

Hopefully the price of video larygoscopes will go down, so the risk associated with advanced airway interventions can be reduced.

 

[southerndoc]

The person intubating is required to call out landmarks as they see them (e.g. lips, teeth, tongue, uvula, arytenoid cartilage, cords...).

That doesn't mean jack squat. Famous words of interns and residents all the time is "yea, I see the cords. Tube is passing through the cords," yet they have no breath sounds and no EtCO2 exchange.

I'm trying to work out an agreement so that the paramedics at my service can spend a day every 6 months in the OR getting intubation experience. They want etomidate, but I'm reticent to give it to them until they show me they can intubate successfully (I just took over medical direction a few months ago).

 

[proman]

The burning question in pre-hospital medicine is .whether .or not we should even be intubating in the field. I personally like to have the skill available in my arsenal, but have come to embrace supraglottic airways, particularly the king device. I believe the majority of pre-hospital intubations probably occur during cardiac arrests, but as DitchDoc73 pointed out, we are moving away from ETI towards supraglottic airways for their ease, rapid placement, and ability to focus on chest compressions. In 99% of OOHCA, I would not be intubating the patient. However, I still intubate other types of patients almost always using a pharmacologically assisted method. Although most paramedics that I work with have numerous intubations each year, I would venture to say that only the flight guys in my area have over 26, which is what the study defines as high (very high). We attempt to correct this lack of exposure by going to cadaver labs and having 2 mac, 2 miller, and 1 bougie manikin intubations every shift before we are able to sign out our narcotics. Additionally, we make intubation a team skill, where if the intubator fails, the whole team fails. No longer is there a case where 1 person is intubating and 1 person is starting an IV. When the laryngoscope is picked up, both people are focused on airway. The person intubating is required to call out landmarks as they see them (e.g. lips, teeth, tongue, uvula, arytenoid cartilage, cords...).

Hopefully the price of video larygoscopes will go down, so the risk associated with advanced airway interventions can be reduced.

Whatever happened to the epiglottis, you know, the thing that gets in the way of actually seeing the cords?

I don't think pharmacologic assisted intubation belongs in the field. I say this as a former 5 year paramedic in Atlanta 911 system and an anesthesiologist.

 

[malkboy]

proman, could you explain your reasons as to why you think PAI does not belong in ems? Do you think we should be intubating at all, and if so when?

southerndoc, I believe calling out landmarks does help, because it keeps everyone apprised of the situation and it encourages people to walk the blade down instead of shoving the blade all the way in. If someone says they saw it pass through the cords and the tube turns out not to be through the cords, there has to be re-education. I hope your OR rotations work out, no matter how advanced the manikins get, you can't beat the real deal.

 

[muffyd]

I work in San Diego as a medic and I believe our system has to be one of the busiest in the country. We have a public/private partnership and they try to squeeze every last dollar out of us by not putting enough ambulances on the street so we end up running about 12 calls in a 12 hour period on our busier units. Even with such a high call volume a typical paramedic might have around 10 intubation attempts per year. This is clearly not enough to keep your skills sharp. Additionally, there does seem to be a lot of evidence pointing to the superiority of outcomes with King airways and so forth. I enjoy intubating and try to get as many tubes in the field and in the ER as I can("hey doc you mind if I give it a shot?"). I try to keep up my skills that in the off chance I encounter a pt who might genuinely need ETI I will be proficient at it. As I see it there are only very rare circumstances in which a pt truly needs ETI. One example would be any kind of laryngeal edema, say smoke inhalation or allergic reaction. Another would be severe respiratory distress/arrest. As for pharma assisted intubation, I'm just not seeing it. Most of your pts who need it don't necessarily need it with in the next 5-10 minutes so unless you have a prolonged transport time I think it can wait. Imagine you find an eighty year old lady, massive intracebral bleed, clenched, clearly aspirated her emesis, the whole deal right. Do you really think her outcome will be improved by prehospital pharma assisted intubation? Beside the fact she probably has less than a few hours to live regardless of her airway status, the amount of further aspiration you can prevent by intubating her on the spot seems pretty insignificant. This is just my take on it and I am fully open to people with different opinions.

 

[MedicFL]

The system I work in is starting to recommend bypassing ET intubation, and going directly to rapidly inserted BLS airways (King Tube, LMA, etc). Our QA/QI director states that our ROSC rates are higher with BLS airways than with ETI. I have heard rumors that our medical director is in the process of doing a study on the impact of airway choice, and I think it may be interesting to see what the results may be!

Thats also partically because the medics in Orange County suck.. The ET sucess rate was terrible as was the number of attempts to get it right. If you havent noticed, maybe you havent. OC has the most basic protocols out there and every revision they keep taking more and more things out of it. Having worked in this system and others I have to say the medics in OC are terrible, and I don't blame them its the QA and training that they get. Im glad OC got rid of their in house medic program because that was turning out some scary medics..

 

[proman]

proman, could you explain your reasons as to why you think PAI does not belong in ems? Do you think we should be intubating at all, and if so when?

My prime reason: receiving patients who were either intubated in the esophagus or had the tip of the tube above the cords (hypopharynx intubation). Done by experience field and flight paramedics. Inexcusable, as was the backtracking "oh the tube must have moved when we got here". BS.

If a patient is strong enough to require drugs to get a tube in, they probably don't need the tube in the immediate transport time. When you remove a patient's drive to breathe with drugs, you remove the safety net of spontaneous ventilation. Nasal intubation is a bit different and much better tolerated without the need for drugs.

I have other reasons to be against it but these are the highlights.

 

[MedicFL]

My prime reason: receiving patients who were either intubated in the esophagus or had the tip of the tube above the cords (hypopharynx intubation). Done by experience field and flight paramedics. Inexcusable, as was the backtracking "oh the tube must have moved when we got here". BS.

If a patient is strong enough to require drugs to get a tube in, they probably don't need the tube in the immediate transport time. When you remove a patient's drive to breathe with drugs, you remove the safety net of spontaneous ventilation. Nasal intubation is a bit different and much better tolerated without the need for drugs.

I have other reasons to be against it but these are the highlights.

Does your system not use capnography? Because with it the chance of a undetected esophagus is 0...

 

[proman]

Does your system not use capnography? Because with it the chance of a undetected esophagus is 0...

I'm an anesthesiologist and use capnography routinely. Even with capnography there's a non zero chance of esophageal intubation going unrecognized. It's not an absolutely perfect monitor.

 

[AegriSomnia]

My prime reason: receiving patients who were either intubated in the esophagus or had the tip of the tube above the cords (hypopharynx intubation). Done by experience field and flight paramedics. Inexcusable, as was the backtracking "oh the tube must have moved when we got here". BS.

If a patient is strong enough to require drugs to get a tube in, they probably don't need the tube in the immediate transport time. When you remove a patient's drive to breathe with drugs, you remove the safety net of spontaneous ventilation. Nasal intubation is a bit different and much better tolerated without the need for drugs.

I have other reasons to be against it but these are the highlights.

The ETT becoming dislodged during the transport/multiple transfers of the patient from floor to board/board downstairs/board to cot/cot to ambulance with the head flopping around is very possible and your capnography will be disconnected. The problem is that placement of the ETT is often not rechecked after movement. I found that securing the patient with a c-collar and even full c-spine if the extrication is down a couple of flights of stairs reduces the amount ETT movement. That really confuses the ED staff though when you roll in with a medical patient in full c-spine.

 

[leviathan]

The key to experience is to simply install a targeted system where you have a majority of BLS providers with a small minority of ALS who only get tagged on high priority calls. I've worked in that system and on a rare occasion they can get 4 or 5 tubes in a single shift.

 

[Paseo Del Norte]

The ETT becoming dislodged during the transport/multiple transfers of the patient from floor to board/board downstairs/board to cot/cot to ambulance with the head flopping around is very possible and your capnography will be disconnected. The problem is that placement of the ETT is often not rechecked after movement. I found that securing the patient with a c-collar and even full c-spine if the extrication is down a couple of flights of stairs reduces the amount ETT movement. That really confuses the ED staff though when you roll in with a medical patient in full c-spine.

Yeah, pretty sad that this still occurs. I make a habit of also printing a strip after every patient move and the last action I take at transfer of care is to print out a strip for myself and a strip that I hand over to the receiving staff. It's pretty difficult to blame a dislodged tube on the flight crew when you have good charting and a nice plateau shaped waveform attached to the chart with a nice time stamp. Not that I have any trust issues with the receiving physicians or staff.

 

[jwk]

I'm an anesthesiologist and use capnography routinely. Even with capnography there's a non zero chance of esophageal intubation going unrecognized. It's not an absolutely perfect monitor.

Some people just don't know what they don't know.

 

[MedicFL]

I'm an anesthesiologist and use capnography routinely. Even with capnography there's a non zero chance of esophageal intubation going unrecognized. It's not an absolutely perfect monitor.

I will have to find the paper I read on Capnography which states about capnography and miss placed tubes, also we did a trial and there is no way to get a actual Co2 value on a capnography if the tube is in the Gut. You will also not have a wave form if you are in the Gut. Even with C02 gas pumped into the stomach there was no way we were able to make the moniter read a C02 value. So I would say that there is a zero chance as long as Capnogrpahy is used and actually paid attention to..No its not perfect but if it is reading 0 and you have no wave form your not in the right spot.. Just as if you have a waveform and a C02 value then you are in the right spot..

 

[MedicFL]

The ETT becoming dislodged during the transport/multiple transfers of the patient from floor to board/board downstairs/board to cot/cot to ambulance with the head flopping around is very possible and your capnography will be disconnected. The problem is that placement of the ETT is often not rechecked after movement. I found that securing the patient with a c-collar and even full c-spine if the extrication is down a couple of flights of stairs reduces the amount ETT movement. That really confuses the ED staff though when you roll in with a medical patient in full c-spine.

A C-collar is the national standard when placing an ET in the field, if medics are not doing this there needs to be some additional training and or corrective actions.. And if you have an arrest you find on the floor or somewhere else where they may have fallen you should be placing them in C-spine anyways..

 

[jwk]

I will have to find the paper I read on Capnography which states about capnography and miss placed tubes, also we did a trial and there is no way to get a actual Co2 value on a capnography if the tube is in the Gut. You will also not have a wave form if you are in the Gut. Even with C02 gas pumped into the stomach there was no way we were able to make the moniter read a C02 value. So I would say that there is a zero chance as long as Capnogrpahy is used and actually paid attention to..No its not perfect but if it is reading 0 and you have no wave form your not in the right spot.. Just as if you have a waveform and a C02 value then you are in the right spot..

Continuing with the "you don't know what you don't know" concept...

http://www.anesthesia-analgesia.org/content/94/6/1534.full

http://www3.interscience.wiley.com/journal/112132951/abstract?CRETRY=1&SRETRY=0

 

[jwk]

A C-collar is the national standard when placing an ET in the field, if medics are not doing this there needs to be some additional training and or corrective actions.. And if you have an arrest you find on the floor or somewhere else where they may have fallen you should be placing them in C-spine anyways..

Show me a link to a "national standard" that says this. It certainly isn't part of any nationally-recognized ACLS protocols.

 

[AegriSomnia]

I don't recall this as being a national standard, either.

 

[MedicFL]

Continuing with the "you don't know what you don't know" concept...

http://www.anesthesia-analgesia.org/content/94/6/1534.full

http://www3.interscience.wiley.com/journal/112132951/abstract?CRETRY=1&SRETRY=0

I will eat my words in a limited trial we performed, we only had two patients for the study and they were postmortem we were not able to create a waveform or get a C02 reading above 3 even when Co2 gas was pumped into the stomach. It would seem it is possible. However in the first article I would tend to maybe agree that the tube may have been dislodged from CPR and other efforts. I have however shared this paper with my PI and further research is def needed in this arena...

 

[jwk]

I will eat my words in a limited trial we performed, we only had two patients for the study and they were postmortem we were not able to create a waveform or get a C02 reading above 3 even when Co2 gas was pumped into the stomach. It would seem it is possible. However in the first article I would tend to maybe agree that the tube may have been dislodged from CPR and other efforts. I have however shared this paper with my PI and further research is def needed in this arena...

You shouldn't be hanging your hat on any single method of confirming tube placement. Every patient in the OR has tube placement verified by EtCO2 waveforms AND auscultation. Remember that for EtCO2 to be present there actually has to be perfusion of the lungs, so you can in fact have proper tube placement and NOT have easily detectable EtCO2.

Far too many are relying on electronic monitors to guide them - they aren't foolproof, they don't always work, and you might not even have them at hand. Don't become so dependent on them that you can't use your eyes and ears to tell you what's going on.

 

[MedicFL]

You shouldn't be hanging your hat on any single method of confirming tube placement. Every patient in the OR has tube placement verified by EtCO2 waveforms AND auscultation. Remember that for EtCO2 to be present there actually has to be perfusion of the lungs, so you can in fact have proper tube placement and NOT have easily detectable EtCO2.

Far too many are relying on electronic monitors to guide them - they aren't foolproof, they don't always work, and you might not even have them at hand. Don't become so dependent on them that you can't use your eyes and ears to tell you what's going on.

I agree 100 percent, I have never and would never count on one single method of confirmation. I work for a flight program so if we tube someone we always try to do it on the ground so we can auscultate, not to mention the space issues trying to tube someone in flight. I think end-tidal is a great tool and when used properly it can greatly reduce the instance of undetected missed tubes. But your correct lungs sounds, visualization, bag compliance are all factors that have to be weighed too.. But thank you for the article def good information...

 

[proman]

The ETT becoming dislodged during the transport/multiple transfers of the patient from floor to board/board downstairs/board to cot/cot to ambulance with the head flopping around is very possible and your capnography will be disconnected. The problem is that placement of the ETT is often not rechecked after movement. I found that securing the patient with a c-collar and even full c-spine if the extrication is down a couple of flights of stairs reduces the amount ETT movement. That really confuses the ED staff though when you roll in with a medical patient in full c-spine.

Could it happen? Sure. Does it happen with nearly the frequency claimed? Hardly. I once had a flight crew claim that the tube must have moved during unloading. The expression on their faces was priceless as I explained the how the ABG completely disproved that.

Far too many are relying on electronic monitors to guide them - they aren't foolproof, they don't always work, and you might not even have them at hand. Don't become so dependent on them that you can't use your eyes and ears to tell you what's going on.

I really like the esophageal detector device for pulseless patients. Low tech and helps corroborate clinical findings in patients who aren't making or exchanging CO2.

 

[proman]

I agree 100 percent, I have never and would never count on one single method of confirmation. I work for a flight program so if we tube someone we always try to do it on the ground so we can auscultate, not to mention the space issues trying to tube someone in flight. I think end-tidal is a great tool and when used properly it can greatly reduce the instance of undetected missed tubes. But your correct lungs sounds, visualization, bag compliance are all factors that have to be weighed too.. But thank you for the article def good information...

So tell me what the gold standard is for confirmation of the position of an endotracheal tube?

 

[docB]

So tell me what the gold standard is for confirmation of the position of an endotracheal tube?

Patient not dying?

In all seriousness clinical elements can be very helpful. If the sat improves, the heart rate stabilizes, color improves, etc. I’m encouraged.

As for a gold standard when I have any doubts I put the blade back in and look. I would say that the gold standard is me seeing the tube going between the cords. Not just the calling out “tube tip passing the cords” bit but really visualizing the tube in the correct position. Granted that’s often difficult with an airway that was tough in the first place but I’d call that the best indicator of correct placement.

Second would be a good waveform capnograph.

Now all of these things get tricky especially with coding patients. I will say that I frequently have patients who are crumping, I tube them, they get worse, drop sats, brady down, I look and see that the tube is good, good sounds, no bounceback on the syringe (I like the esophageal detector device too) and that’s just how it goes. With a bad PE or an MI in cardiogenic shock an so on you can certainly have a good tube and a bad outcome.

 

[Paseo Del Norte]

There will be a measure of uncertantly associated with every technique or modality utilised; however, I would say waveform capnography certainly is both highly sensitive and specific in most cases.

With that, I am of the opinion that the "gold" standard should include a constellation of objective and subjective findings that are consistent with a properly placed tube in the trachea.

Things I consistently check after moving a patient:

Chest rise and fall
Epigastric auscultation and a 4 point auscultation
The tube depth and compare to prior findings
Waveform capnography
Look at the SPO2 and rhythm strip

I actually carry a bulb for the case of cardiac arrest and I find I can quickly gain a high degree of combitube placement confidence by throwing a bulb on the two lumens.

 

[Apollyon]

Gold standard? Three of them - direct visualization (either outside with the eye or a camera or inside the tube with bronch), CT/MRI, and autopsy. Go for the first two.

 

[southerndoc]

There is no real gold standard. Even when people say they see the cords, it's still not fool proof. I've heard plenty of times "I saw it pass through the cords" only to find it a gut tube. Either they're lying about seeing it pass through the cords, or they are confused what the cords look like.

Even a combination of everything isn't 100% fool proof, but I think end-tidal CO2 detection (except in cardiac arrests), direct visualization, breath sounds, and oxygen saturation of 95+% (except in cardiac arrest) is required to confirm placement. The esophageal detector device should be used in cardiac arrests as an additional measure.

I am carefully reviewing intubations performed by paramedics where I am medical director. If there is a problem with undetected esophageal intubations, then I can easily revoke their airway privileges. Most studies I am familiar with don't show an improvement in mortality with patients tubed in the field.

 

[proman]

Patient not dying?

In all seriousness clinical elements can be very helpful. If the sat improves, the heart rate stabilizes, color improves, etc. I’m encouraged.

Second would be a good waveform capnograph.

Now all of these things get tricky especially with coding patients. I will say that I frequently have patients who are crumping, I tube them, they get worse, drop sats, brady down, I look and see that the tube is good, good sounds, no bounceback on the syringe (I like the esophageal detector device too) and that’s just how it goes. With a bad PE or an MI in cardiogenic shock an so on you can certainly have a good tube and a bad outcome.

The gold standard is accepted as fiberoptic bronchoscopy. Obviously that isn't always an available option, but when it's there it takes 2 seconds to slip the bronch in and see some sort of lung anatomy. We've established difficult airway carts (at great expense) and distributed them across the hospital, including the ER. They have a full complement of fiberoptic scopes and ENT intruments, along of surgical airway kits.

I agree that clinical improvement helps add confidence. The benefit of a nonparalyzed patient is that they still have spontaneous ventilaton. So even if the tube is not in the trachea, these patients rarely suffer hypoxic brain injuries (related to the esophageal intubation).

Gold standard? Three of them - direct visualization (either outside with the eye or a camera or inside the tube with bronch), CT/MRI, and autopsy. Go for the first two.

Yes, but of the three you've listed, only bronch is reasonable realtime evidence. But we're talking about prehospital intubation, and I recognize that FOB isn't an option. What is available is capnography and esophageal detector devices. Sustained capnography, is probably the best option to establish intubation. But it doesn't help with mainstem placement or when the tip of the tube is above the cords (a scenario that I think happens very frequently in the field). Like usual, the pathologist is late to the party.

Even a combination of everything isn't 100% fool proof, but I think end-tidal CO2 detection (except in cardiac arrests), direct visualization, breath sounds, and oxygen saturation of 95+% (except in cardiac arrest) is required to confirm placement. The esophageal detector device should be used in cardiac arrests as an additional measure.

I am carefully reviewing intubations performed by paramedics where I am medical director. If there is a problem with undetected esophageal intubations, then I can easily revoke their airway privileges. Most studies I am familiar with don't show an improvement in mortality with patients tubed in the field.

I like the syringe version of the esophageal detector, but both the bulb and syringe have been shown to have false positive (esophageal) results from plugging in pulmonary edema/aspiration scenarios. As you guys have discussed the bad thing about capnography is that it depends on a reasonable cardiac output to produce and exchange gas.

As for the physical exam, I think it's much less reliable. I've heard breath sounds transmitted across the chest (plus we all know how noisy the diesel busses are). Chest rise is something that not easy to see. I'm a fan of ballotting the pilot balloon (high specificity, low sensitivity) in the suprasternal notch.

Back to the field, I think the most reasonable approach of confirming placement, understanding the limitations, would be

1) Direct visualization via laryngoscopy
2) Use of a syringe esophageal detector device for initial placement, with physical exam including ballottment of the balloon.
3) Continuous capnography

My argument that the tube doesn't commonly jump out of the trachea to the esophagus on transferring patients still stands.

 

[docB]

The gold standard is accepted as fiberoptic bronchoscopy. Obviously that isn't always an available option, but when it's there it takes 2 seconds to slip the bronch in and see some sort of lung anatomy. We've established difficult airway carts (at great expense) and distributed them across the hospital, including the ER. They have a full complement of fiberoptic scopes and ENT intruments, along of surgical airway kits.

I agree that clinical improvement helps add confidence. The benefit of a nonparalyzed patient is that they still have spontaneous ventilaton. So even if the tube is not in the trachea, these patients rarely suffer hypoxic brain injuries (related to the esophageal intubation).



Yes, but of the three you've listed, only bronch is reasonable realtime evidence. But we're talking about prehospital intubation, and I recognize that FOB isn't an option. What is available is capnography and esophageal detector devices. Sustained capnography, is probably the best option to establish intubation. But it doesn't help with mainstem placement or when the tip of the tube is above the cords (a scenario that I think happens very frequently in the field). Like usual, the pathologist is late to the party.



I like the syringe version of the esophageal detector, but both the bulb and syringe have been shown to have false positive (esophageal) results from plugging in pulmonary edema/aspiration scenarios. As you guys have discussed the bad thing about capnography is that it depends on a reasonable cardiac output to produce and exchange gas.

As for the physical exam, I think it's much less reliable. I've heard breath sounds transmitted across the chest (plus we all know how noisy the diesel busses are). Chest rise is something that not easy to see. I'm a fan of ballotting the pilot balloon (high specificity, low sensitivity) in the suprasternal notch.

Back to the field, I think the most reasonable approach of confirming placement, understanding the limitations, would be

1) Direct visualization via laryngoscopy
2) Use of a syringe esophageal detector device for initial placement, with physical exam including ballottment of the balloon.
3) Continuous capnography

My argument that the tube doesn't commonly jump out of the trachea to the esophagus on transferring patients still stands.

Good points. I didn't think of bronch as we don't have them available where I work.

What about a specialized, scaled down bronch designed just for ETT verification? It wouldn't need steering or ports and wouldn't need an insanely strong light source. It probably wouldn't need to be fiberoptic. Just an LED and a camera on the end of a flexible baton kind of like a Glidescope would work.

Now that I've given away my billion dollar idea and ticket out of clinical medicine on a more mundane note I actually seen more esophageal tubes in patients whe were still breathing because the medics really did hear breath sounds and mistook them to mean the tube was good.

 

[proman]

We use pediatric sized bronchoscopes primarily for placement of double lumen tubes. There are a variety of bronchs that are battery powered and highly portable (uses a 3v battery).

The picture shows a pedi bronch with an Aintree catheter loaded on it. The Aintree is my preferred method of intubating unanticipated difficult airways. First place an LMA and ventilate with it, then place the FOB through the LMA and leave the Aintree behind. Then just railroad the ETT over the Aintree. I've used this method in all settings, including the MICU with a known difficult airway during CPR.

Hit this link for UF's describtion

 

[proman]

Another point about a pitfall of capnography:

We've had several cases of severe bronchospasm after induction (usually happens in snot filled kids) where the tube has been correctly placed and there's no EtCO2. People tend to rely so much on capnography that they extubate and reintubated, sometimes multiple times. I'm not sure how the esophageal detector would act, likely as in a esophageal intubation. As you can imagine, these patients deteriorate rapidly, even the the tube was well positioned. I'd imagine the same could happen in the ED/field with asthma.

 

[DitchDoc73]

Thats also partically because the medics in Orange County suck.. The ET sucess rate was terrible as was the number of attempts to get it right. If you havent noticed, maybe you havent. OC has the most basic protocols out there and every revision they keep taking more and more things out of it. Having worked in this system and others I have to say the medics in OC are terrible, and I don't blame them its the QA and training that they get. Im glad OC got rid of their in house medic program because that was turning out some scary medics..

Wow...Productive and on topic post...I get it...You don't like OC, or it's medical directors...You point this out in every thread you get a chance to...Let me guess...Former RMA medic before you moved on to bigger and better things? Get over it dude...EVERY system in the country has their share of good medics, and their share of ******s.

As far as the so called "study" that was performed about pre-hospital ETI, it was shown to be flawed. Tube confirmation was performed by having the Resident visually confirm placement. If the Resident said that the tube was not in the trachea, they then got to extubate and re-intubate the Pt. Gee....Think their might be a reason for a Resident to say the tube wasn't in place. When the "study" was repeated requiring X-ray confirmation of tube placement, the numbers were found to be significantly skewed in the first study. Also I don't know where you get this significant number of attempts junk...OC medics are only permitted 2 ETI attempts (if they chose to attempt) in medical cases before being required to move on to other airways.

What is your beef with their QA?

I will agree with you on the "in-house" paramedic class. The level of inconsistency with the paramedics was a definite problem. Too much teaching of protocols.

 

[MedicFL]

Wow...Productive and on topic post...I get it...You don't like OC, or it's medical directors...You point this out in every thread you get a chance to...Let me guess...Former RMA medic before you moved on to bigger and better things? Get over it dude...EVERY system in the country has their share of good medics, and their share of ******s.

As far as the so called "study" that was performed about pre-hospital ETI, it was shown to be flawed. Tube confirmation was performed by having the Resident visually confirm placement. If the Resident said that the tube was not in the trachea, they then got to extubate and re-intubate the Pt. Gee....Think their might be a reason for a Resident to say the tube wasn't in place. When the "study" was repeated requiring X-ray confirmation of tube placement, the numbers were found to be significantly skewed in the first study. Also I don't know where you get this significant number of attempts junk...OC medics are only permitted 2 ETI attempts (if they chose to attempt) in medical cases before being required to move on to other airways.

What is your beef with their QA?

I will agree with you on the "in-house" paramedic class. The level of inconsistency with the paramedics was a definite problem. Too much teaching of protocols.

No I never worked for RMA, and no actually while working on my masters I did alot of work with the Medical directors and they are great doctors who I hold alot of respect for. The reasoning the Protocols are the way they are, because of a combination of factors. One of them being lack of trust in field medics, short transport times, and probally the biggest is evidence based medicine. I will have to hand it to the OC medical directors they study the facts before they added something or removed something from protocols.. And when I say OC I dont just mean Orange County FD i mean the system as a whole including OFD, RMA, HC, and OCFR. I don't mean to come acrossed as negative, however coming from another I was just highly disappointed with what I saw, the amount of money and resources that OC has I just expected more. I am not longer in Orange County so maybe things have changed...

 

[jwk]

We use pediatric sized bronchoscopes primarily for placement of double lumen tubes. There are a variety of bronchs that are battery powered and highly portable (uses a 3v battery).

The picture shows a pedi bronch with an Aintree catheter loaded on it. The Aintree is my preferred method of intubating unanticipated difficult airways. First place an LMA and ventilate with it, then place the FOB through the LMA and leave the Aintree behind. Then just railroad the ETT over the Aintree. I've used this method in all settings, including the MICU with a known difficult airway during CPR.

Why not just slide an ETT through the LMA, or better yet, use an LMA FastTrach specifically designed for that purpose? If you're ventilating with an LMA, the last thing I'd want to do is remove a functioning airway in a patient with a difficult airway and (hopefully) replace it with another, even if you have a ventilating catheter in as a guide.

I've never seen the catheter threaded over the bronchoscope like that though - neat trick I'll have to remember.

 

[DitchDoc73]

Why not just slide an ETT through the LMA, or better yet, use an LMA FastTrach specifically designed for that purpose? If you're ventilating with an LMA, the last thing I'd want to do is remove a functioning airway in a patient with a difficult airway and (hopefully) replace it with another, even if you have a ventilating catheter in as a guide.

I've never seen the catheter threaded over the bronchoscope like that though - neat trick I'll have to remember.

Cost and Training issues are the main reasons usually...

 

[proman]

Why not just slide an ETT through the LMA, or better yet, use an LMA FastTrach specifically designed for that purpose? If you're ventilating with an LMA, the last thing I'd want to do is remove a functioning airway in a patient with a difficult airway and (hopefully) replace it with another, even if you have a ventilating catheter in as a guide.

I've never seen the catheter threaded over the bronchoscope like that though - neat trick I'll have to remember.

I've tried to like the FastTrach. Given it multiple attempts on elective cases. Not once did it go smoothly. It feels like using Erector Sets. I certainly wouldn't pick the blind technique vs one where I get to see what happens. As for the tube through the LMA, that works sometimes, but there's no easy way to get the LMA out. It's certainly a reasonable option in an emergency, and usually works.

The LMA-Fiberoptic-Aintree is a great approach. I've timed myself and I can do it in under a minute. Cutting the LMA's plastic grill if time permits makes it even easier. It is my personal backup method (assuming fiberoptic is available). The key to have a backup plan and a method the person managing the airway is expert at.

Cost and Training issues are the main reasons usually...

Vast majority of hospitals have fiberoptic scopes available. The Aintree catheter is probably a couple of dollars. You could buy a million Aintrees for the cost of a lost airway. Training is fairly straightforward (definitely <5).

 

[Dwindlin]

Anyone had a chance to play with one of these yet?

http://www.mdimicrotek.com/prod_salt.htm

Called a SALT, place it like an OPA then put the tube through it. I haven't had a chance to try it on a real person, but playing with the manikins it works great.

 

[docB]

Vast majority of hospitals have fiberoptic scopes available.

The hospitals have them but their availability to the ED in a timely manner is spotty at best. In many places they are kept in the OR and a nursing sup or security guard is required to open it up at neight and during the day OR staff has been known to get territorial and not let them leave the OR. It is better when they are kept in the ICU but that's still time you don't have.

 

[proman]

The hospitals have them but their availability to the ED in a timely manner is spotty at best. In many places they are kept in the OR and a nursing sup or security guard is required to open it up at neight and during the day OR staff has been known to get territorial and not let them leave the OR. It is better when they are kept in the ICU but that's still time you don't have.

Do you have a difficult airway cart in the ER? When's the next time you get to ask for capital expenditure? I think a FOB is about $15,000. The best approach to this is to ask your hospital's malpractice carrier what the payouts were for its airway related cases.

 

[jwk]

The hospitals have them but their availability to the ED in a timely manner is spotty at best. In many places they are kept in the OR and a nursing sup or security guard is required to open it up at neight and during the day OR staff has been known to get territorial and not let them leave the OR. It is better when they are kept in the ICU but that's still time you don't have.

Ours (anesthesia) are in the OR, and they stay there on our difficult airway carts. We have had them "borrowed" by the ER in the past, they don't return them, and when we get them, they're damaged or missing parts. No more - now they're locked up where only we have access to them. If the ER needs one, they can get it out of their capital budget just like we do. We don't even let our thoracic surgeons use ours anymore - they have to use one from the OR or endoscopy lab - same reasoning.

It amazes me how much money is spent on big-ticket PR items in hospitals that are used infrequently (things like surgery robots) and how little is sometimes spent on things we NEED and use every day.

 

[jwk]

Anyone had a chance to play with one of these yet?

http://www.mdimicrotek.com/prod_salt.htm

Called a SALT, place it like an OPA then put the tube through it. I haven't had a chance to try it on a real person, but playing with the manikins it works great.

If it was that great, EVERYONE would be using them. They're not. These are devices intended for those who don't/can't intubate with any regularity and need a trick to fall back on.

 

[DitchDoc73]

Vast majority of hospitals have fiberoptic scopes available. The Aintree catheter is probably a couple of dollars. You could buy a million Aintrees for the cost of a lost airway. Training is fairly straightforward (definitely <5).

Sorry I was talking about EMS, not in hospital...Most public EMS agencies have significantly decreased liability limits through state legislation.

My agency was looking at disposable glidescopes for ETI, but the per unit cost was deemed to be too high. They also looked at ETI through LMA devices, and once again the cost per unit was deemed to be too high for our system. As far as training goes, yes it is straightforward, but when you are talking about putting 1,000 employees through a 4 hour training class, the costs mount very quickly.

 

[DitchDoc73]

No I never worked for RMA, and no actually while working on my masters I did alot of work with the Medical directors and they are great doctors who I hold alot of respect for. The reasoning the Protocols are the way they are, because of a combination of factors. One of them being lack of trust in field medics, short transport times, and probally the biggest is evidence based medicine. I will have to hand it to the OC medical directors they study the facts before they added something or removed something from protocols.. And when I say OC I dont just mean Orange County FD i mean the system as a whole including OFD, RMA, HC, and OCFR. I don't mean to come acrossed as negative, however coming from another I was just highly disappointed with what I saw, the amount of money and resources that OC has I just expected more. I am not longer in Orange County so maybe things have changed...

I'm sorry, not trying to hijack this thread...I will bring this topic back in line with the overall topic! I promise! lol

That's what I have always said about the OCMD's office is that their protocols are very conservative. But they are that way for specific reasons (very large system, short transport times as a whole, evidence based medicine, etc). The medical directors would have a tough time meeting, let alone getting to know every provider in their system (considering that they cover approximately 2,500 EMTs and Paramedics). I'm not sure of the overall numbers for the system, but I know most of OCFRD's numbers. OCFRD's ROSC rate is consistently in the 24-28% range, unfortunately they do not follow these numbers to hospital discharge. I'm not sure what more you could expect? I am going to bring this back in to the overall topic of this thread now. One trend that has been noticed is that when the providers on scene bypass ETI attempts and go directly to the King tube, the rate of ROSC increases (especially in asystole patients). I am not advocating taking this valuable skill away from Paramedics, but sometimes Paramedics need to realize that their "non-profficiency" in a skill definitely can have negative effects on patient outcome.

 

[docB]

Do you have a difficult airway cart in the ER? When's the next time you get to ask for capital expenditure? I think a FOB is about $15,000. The best approach to this is to ask your hospital's malpractice carrier what the payouts were for its airway related cases.

The hospital's payouts for airway disasters = $0. Ours as independent contractors is a different story. But as you can imagine the hospital's interest in buying us new equipment takes a back seat to other things, especially in this economy. We just recently got an ultrasound.

 

[proman]

I'm sorry, not trying to hijack this thread...I will bring this topic back in line with the overall topic! I promise! lol

That's what I have always said about the OCMD's office is that their protocols are very conservative. But they are that way for specific reasons (very large system, short transport times as a whole, evidence based medicine, etc). The medical directors would have a tough time meeting, let alone getting to know every provider in their system (considering that they cover approximately 2,500 EMTs and Paramedics). I'm not sure of the overall numbers for the system, but I know most of OCFRD's numbers. OCFRD's ROSC rate is consistently in the 24-28% range, unfortunately they do not follow these numbers to hospital discharge. I'm not sure what more you could expect? I am going to bring this back in to the overall topic of this thread now. One trend that has been noticed is that when the providers on scene bypass ETI attempts and go directly to the King tube, the rate of ROSC increases (especially in asystole patients). I am not advocating taking this valuable skill away from Paramedics, but sometimes Paramedics need to realize that their "non-profficiency" in a skill definitely can have negative effects on patient outcome.

The safest, cheapest, most effective way is not to allow drugs to intubate a patient. The patient who can be intubated without drugs (arrest, bad CHF/COPD) is another story. BTW I think the Glidescope is a fantastic device and clearly the leader in the field. The disposable one is great.

The hospital's payouts for airway disasters = $0. Ours as independent contractors is a different story. But as you can imagine the hospital's interest in buying us new equipment takes a back seat to other things, especially in this economy. We just recently got an ultrasound.

What are you using the ultrasound for? Would you be able to get a reduction on your group's malpractice premium if you provided a difficult airway cart?

 

[Apollyon]

What are you using the ultrasound for? Would you be able to get a reduction on your group's malpractice premium if you provided a difficult airway cart?

The U/S mention wasn't in regard to airways. He was going for the slow movement towards technology in his shop.

 

[DitchDoc73]

The safest, cheapest, most effective way is not to allow drugs to intubate a patient. The patient who can be intubated without drugs (arrest, bad CHF/COPD) is another story. BTW I think the Glidescope is a fantastic device and clearly the leader in the field. The disposable one is great.

I would agree with that. With CPAP / BiPAP the need for RSI is significantly decreased IMO (yes I know there are still situations where RSI is needed, but they are generally few and far between).

I really liked the glidescope, but unfortunately the cost per unit was deemed to be too high...for now.

 

[proman]

The U/S mention wasn't in regard to airways. He was going for the slow movement towards technology in his shop.

Really?