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Nasotracheal Intubation of Apneic Patient

40 posts in this topic

Posted (edited) · Report post

Hi, 


So I ran into an interesting scenario today at work.  We were on scene at a code and the patient presented with clenched teeth which we had no luck in intubating.  We have no RSI protocol in our system... As my partner raced back to the truck to retrieve the cric kit and IO drill  (we didn't know we were walking into a code) and the first responders were taking care of BLS I decided I would try the "absolutely contraindicated" nasotrachael intubation of our apneic patient (As an EMT-Intermediate I cannot do surgical airways).  It went right in and functioned perfectly within about 8 seconds.  My partner finally got back and was was shocked and confused about how it worked with no inspiration to guide it in.  I guess I attribute it purely to luck but it got me thinking-- In classes and from talking to MDs and respiratory therapists, you cannot and should not ever try to go nasally with an ET tube on a non breathing patient (indeed I got chewed out at the ER).  Does anyone else have any experience on this issue? I know the procedure is not intended for code situations, but it seemed to work so easily and quickly to be so harshly contraindicated in this situation.  Obviously if other more reliable and indicated means were available (surgical procedures, RSI, etc.) that would be the better option, but what about if they are not readily at hand or a paramedic level provider is not present?

Edited by twist27896
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Posted · Report post

I'm perplexed by your post. The first thing I can offer is yes, it was probably dumb luck that your nasotracheal intubation attempt of an apneic patient was successful. That being said, good for you. You thought outside the box and improvised when conventional measures failed. Was it contraindicated? Yes, but I would argue only relatively. If the goal is to optimize oxygenation, which it is, you succeed. Two questions remain. The first is for your service: why isn't your surgical airway kit with the rest of your advanced airway equipment? You just learned a hard lesson and that is you cannot always predict the failed airway. You can assume a difficult airway, which you did, but did not have the appropriate equipment prepared when you needed it in a hurry. The second question is a physiological one: why was this patient clenched? Trismus is normally associated with muscular contraction, which should cease actor shortly after the time of cardiac arrest. Paralytics used in RSI should provide no benefit in the case of arrest because the patient should already be relaxed as muscles cannot contract without oxygen (for very long) and oxygen is not supplied without circulation, nor is carbon dioxide eliminated, which will further, indirectly, lead to the absence of a muscular contraction. Yes, I'm aware that there is a lot more that goes into the function of skeletal muscle but that's beyond the scope of this comment. My only other comment, and you may have just not mentioned it, is don't forget the basics. A nasal airway and a BVM make a very effective bridge to definitive airway placement in the clenched patient, in most cases assuming the absence of secretion or emesis and an adequate mask seal. I'm sure you thought of it but never neglect oxygenation for the purpose of airway placement. The airway does nothing to affect outcome if we allow hypoxia, especially prolonged hypoxia, in the interim.
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Posted · Report post

Brother,I'm confident that this is a theoretical question posed as first person fact, for the reasons mentioned above as well as others...

 

Great response Cykes!

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Posted (edited) · Report post

I agree 100% that we should have our surgical airway stuff in our jump bag, but I guess due to budget constraints we only have one kit on the truck in the airway cabinet.  The first responders had already placed an NPA while we were setting everything up. I am sure that the success was blind luck but my question is, should you ever try to do it in a similar situation?  I mean every piece of literature, protocol, and advice says no but if it worked once and you are between a rock and a hard place, would it not be something to at least  consider?  As far as why the teeth were clenched we don't know unfortunately.  The only history we were given was a methadone abuse and hx. of back surgery. I'm not a paramedic so I don't really know that much about RSI actually but I guess for non-code situations it might come into play? I could be missing ALOT of something here since I am not at the full Paramedic level which is what I am wondering.

Edited by twist27896
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Posted · Report post

Even a broken clock is right twice a day, so be careful with that line of reasoning.  Don't forget that not everyone needs a definitive airway.  If you can oxygenate/ventilate with an NPA/BVM, then don't fix what ain't broke.  Another question I have, is what was the cause of the code.  Was this an OD?  Would the pt have benefited from narcan?  What do you mean by "code"?  I've come to find that different people have different definitions.

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Posted (edited) · Report post

We don't really know the cause unfortunately.   We gave the usual round of code drugs (including 2 rounds of narcan).  The medic and doctors wanted a definitive airway so that was really the only reason I that I tried to get one than avoiding aspiration and reducing gastric air.  As for it being a "code", it was an unwitnessed cardiac arrest in asystole. We walked into a report that the patient had "fainted".

Edited by twist27896
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Posted · Report post

How long was patient down again?  Why did you transport Asystole?  Just asking, not confronting?  

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Posted · Report post

I think it might have been easier to just not commence resuscitation, or to have ceased.  Asystole with two rounds of adrenaline ain't looking good.

 

In the absence of such and  if a definite airway was desired then whoever desired it should have performed the procedure.

 

Curiously, what did you want?

Personally, I reckon an NPA with a good jaw thrust or an LMA would suffice quite nicely

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We are working on being allowed to call asytole in the field but as of now we have to work it and transport for the ER to discontinue resuscitation unless obviously dead :\ We don't carry LMAs and we couldn't get the mouth open to use a normal adjunct.  NPA was working and seemed to be effective.  Just wondering if anyone has done this before and/or where there stance is on apneic nasal intubation. Pt was down for maybe 10 min? It was unwitnessed so it is kinda uncertain.

Edited by twist27896
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Everything I'm reading, and have ever read, about nasotracheal intubations has stated that the patient must be breathing to facilitate tube placement. Given what you've posted here I think you simply got lucky with the tube placement. I would not count on that happening again.

Without trying to distract too much from your original question I think you've unwittingly raised some excellent questions and discussion points. Was there a functioning NPA with effective bag mask ventilations ongoing when you arrived? Current ACLS guidelines don't advocate for advanced airway placement if effective bag mask ventilations can be maintained. If you're being forced to transport then maintaining effective BM ventilations can be difficult and I can understand the desire for an advanced airway. However, your comment about "obviously dead" makes me wonder if perhaps a phone call to your command doc with an explanation of an unwitnessed arrest, unknown downtime, asystole in three leads, and two rounds of drugs with no ROSC would meet your stated criteria for "obviously dead".

I'm interested to hear if CHBARE has any additional insight on the nasotracheal tube discussion.
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You seem to be missing a lot of details on "your" call which perplexes me....I also would like to know how long the pt was down before you arrived. Are you sure he hadn't been down so long that rigor had set in? Rumor has it that it starts in the jaw first....just a question mind you....

 

You also state that First Responders were taking care of BLS...I'm guessing that means they had the AED attached and were performing high quality CPR all with an NPA in place that was efficient?

 

Which brings me to my question then of why you would even take it upon yourself then to decide this wasn't adequate and go against "absolute contraindications" to use nasotrachael intubation while a higher level provider "ran out to the truck to get the IO and cric kit"...I'm just having a hard time swallowing this statement.

 

In my neck of the woods if the medic wants a more secure airway, the medic gets a more secure airway and doesn't request that another provider goes against contraindications and protocols to obtain one....I'm not real comfortable with your statement that you attribute it to "pure luck" and doesn't give me a warm fuzzy feeling that someone who appears to be so blatantly proud of going against proven procedures is providing care...

 

I agree with ERDoc that even a broken clock is right two times a day~~

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Posted · Report post

So what would have happened if you tubed the stomach? Would you have just pulled it out? Left it in place? Documented the attempt?

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Posted (edited) · Report post

Woulda left it in place to block the hole and shoved another tube down the other nostril. :)

 

I finally have a couple of days off so this might be the vast quantity of Irish Coffee talking...but wtf is an intermediate provider doing a nasotracheal intubation for anyways?  Is there anyplace where ETT placement is an Intermediate skill, let alone NTT?  Methinks someone is very lucky he doesn't have stinging fingers 'cause I sure as hell would have rapped them before kicking is ass out of my organisation.

 

 

Edit, I meant to put Intermediate and had BLS in error.

Edited by Arctickat
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Hey now, he said he was an Intermediate... I'm also having a lot of problems with this call.  Why would someone who has been down for an unknown length of time have a clenched jaw... I've seen this in head trauma but relaxes promptly with the loss of a pulse.  Can someone explain a physiologic condition (other than rigor) that would cause this?

 

I've never heard of a jurisdiction that does not have a DOA protocol...  if this was rigor did you just mess with a potential crime scene?

 

Why would you just for the hell of it try a NTT without your medic partner there, stopping CPR and effective ventilations?

 

There is just stuff that isn't adding up... did you document you placed the NTT?  What has your medical director said of all this?

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Posted · Report post

Yes Kat there are many places where Intermediates can intubate and have for many years. 

Properly educated and trained it has been a standard of care for over a decade.

I would not have even thought about pulling the nasal airway to try a blind insertion  nasal ETT on a dead guy, especially given the unknown down time and the drug abuse hx. He would have gotten CPR, IV ,a couple rounds of epi & narcan to try & reverse a potential opiod causation of the arrest.

After 20 minutes call it right there.

Dead guys don't often get better.

 

PS. I have run into a narcotic overdose arrests with trismus.

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Actually Kat, ETT is in my bag of skill sets although in all honesty, the only time I've used it is testing and for skills maintenance. I have used Combi-tube as my first "go to" airway everytime......

 

NTT however is not and I can not find it in any of my surrounding state Intermediate protocols....

 

I think I'm sticking by my original thought that this question is a pose as there seems to be too many details that do not add up....

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Hey guys, I'll try and clear up some questions.  In NC EMT-I's can intubate orally and nasally in many places.  I honestly don't know why trismus persisted (it might have very well been rigor--I honestly don't know) although rigor didn't appear anywhere else that we could tell. The down time was heavily estimated as the arrest wasn't witnessed. We are in a transition phase with a new chief and policy overhaul and they temporarily took away the ability to terminate resuscitation unless rigor has obviously set in, DNR, or trauma inconsistent with life.   The only thing we did know for sure is about the drug abuse hx.  I am definitely not proud or "happy" that I did something in a grey area just wondering if anyone has ever heard of it being tried before.

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I'm surprised that chbare hasn't chimed into this conversation yet.

 

I don't know why it's contraindicated, but my guess would be that the odds of it being necessary would be almost nonexistant, particularly having such a patient as mentioned here, as well the odds of success being dismal, combined with the damage that someone that would try such a thing would likely do to the airway anatomy while they bashed the tube around hoping for their "lucky shot."

 

Chbare tells us that tons of damage is often accidently done by paramedics doing normal ett placements, I can't imagine that doing blind netts would be any better, and almost certainly worse.

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Since the circumstances of this call make no sense to me right now, to be clear, your ACP partner went back to the ambulance, leaving the you, the lesser qualified practitioner to get the cric and IO kits before knowing that the patient was in cardiac arrest and before even assessing the need for a surgical airway or attempting an IV? This makes no sense.. This must be a hypothetical situation of some sort.

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There are many good comments already and all I can do is confirm what has been said.  Getting the nasal tube into the trachea was pure dumb luck and will happen once in a hundred times.  There are many ways to manage an airway effectively and having a tube in the trachea is only one of them and it is not high on the list.  The AHA ACLS materials have lowered the emphasis on getting the patient intubated because it all to often interrupts compressions.  Requiring transport of a patient in asystole that has not responded to aggressive ALS interventions is also not recommended by the AHA. 

 

Obvious signs of death?  Asystole and clenched jaws that can't be opened?  Can anybody say rigor mortis?  

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Obvious signs of death?  Asystole and clenched jaws that c

 

Obvious signs of death?  Asystole and clenched jaws that can't be opened?  Can anybody say rigor mortis?  

 

Well the clenched jaws could have been that he had broken his jaw, then had it wired shut.  Hey it's as likely as getting a nasal tube on a asystolic patient right?  

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Posted · Report post

I'd be interested in discovering how much trauma resulted from the airway insertion.

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Got a good laugh from that response Captain!

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While certainly not best, 'blind' nasal intubation still remains common practice. I've done one of my clinical rotations in the anaesthesia department of a maxillo-facial surgery unit where most ETIs were done nasally. I was shocked (on my first day) to see the senior anaesthetist simply 'shove' the tube down the patients nose without even touching the laryngoscope (and stethoscope for that matter). Still, I haven't seen any of his intubation attempts fail... Some of the other consultants used the same technique. Trick is not to tilt the head backwards, basically get it into a Jackson kind of position.

 

Mind you, these guys had 10+ years of experience doing exactly that day in, day out. I'm fairly certain none would attempt it in a code situation.

 

Now the interesting question is, why was the jaw clenched??? Any kind of trismus would cease during arrest, possibly the clenched jaw was due to surgery or radiation therapy? To be honest, Spock is probably right.

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I'm surprised that chbare hasn't chimed into this conversation yet.
 
I don't know why it's contraindicated, but my guess would be that the odds of it being necessary would be almost nonexistant, particularly having such a patient as mentioned here, as well the odds of success being dismal, combined with the damage that someone that would try such a thing would likely do to the airway anatomy while they bashed the tube around hoping for their "lucky shot."
 
Chbare tells us that tons of damage is often accidently done by paramedics doing normal ett placements, I can't imagine that doing blind netts would be any better, and almost certainly worse.


I'm sorry bro, not much else I can add to the conversation. Clearly a patient with spontaneous respirations will be a better candidate for NT intubation. However, in light of all the evidence, I am not sure anything beyond a nasal airway and conventional ventilation would have been really indicated in this situation assuming the apparent trimsmus was not rigor mortis.
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