Camulos

As the general consensus seems to be that it is dumb to go into potentially hostile situations unarmed, please educate us with your wisdom on why it is not dumb oh learned SWAT / Army / ER hero. Just my $0.04 to add to this FORUM Stay safe, Camulos

Can you please tell me why Australia no longer recognizes abdominal thrusts? As stated by the Australian Resuscitation Council – "The ARC does not recommend the use of abdominal thrusts as there is considerable evidence of harm caused by this procedure". The "evidence" (if it can be referred to as that) by ILCOR in 2005 cites twenty two separate case reports of adverse events secondary to the abdominal thrust procedure. Some of the adverse events noted in this literature review included gastric rupture, abdominal aortic thrombosis, internal carotid artery dissection, mesenteric laceration, diaphragmatic hernia, pneumomediastinum, ruptured oesophagus and vomiting with subsequent aspiration. Although not specifically cited by the ARC as a reason to abolish abdominal thrusts it is interesting to note three studies that exhibit that higher airway pressures can be generated by using chest thrusts rather than abdominal thrusts. One was a randomised trial using cadavers and the other two were prospective studies utilising anaesthetised volunteers. Without an official statement by the ARC however one can only postulate whether these studies weighed into their decision making process on this topic. However being only three small studies I would think, or hope, not. Can you tell me when Australia did away with abdominal thrusts? February 2006 – Based on ILCOR recommendations from 2005. Can you tell me why a medic (if following the guidelines as written) would have to wait for the patient to decompensate before being able to assist if the back blows don't work and they don't lay down? The topic of chest thrusts did cause some confusion when first published. One misunderstanding here was the positioning of a casualty to be administered chest thrusts. As you seem to have been incorrectly informed it is NOT compulsory for the pt to be lying down to have chest thrusts administered. Lying down is one possibility however you have already highlighted the improbability of the pt cooperating with that approach. Therefore as it states in the ARC guidelines when referring to chest thrusts - "Children and adults may be treated in the sitting or standing position". Furthermore on the topic of chest thrusts the ARC states; "Chest thrusts are applied: • At the same point on the chest that is used when providing chest compressions during CPR. • They are delivered sharper and slower than chest compressions during CPR. In order to do chest thrusts you need to have the back of the patient supported. This can be achieved by either: • Placing your other hand on the patients back. • If the patient is sitting use your other hand to support the back of the chair. • Have someone stand behind to provide support. • Stand against a firm surface like a wall. • Lie the patient down. It is very hard to state categorically on how to achieve back support when using chest thrusts but the overall principle remains the same. Support the back any way you can. Remember if chest thrusts cannot be applied continue with back blows. If the patient becomes unconscious commence CPR." I have not touched on the role here of larnygoscopy and magills as I believe that would be a whole new topic in itself. I hope this helps and if you really want the actual references for any of the above just let me know. What an interesting post that is going to make – LOL. Stay safe, Camulos

I'm sure this was mentioned on the forums here not too long ago. Look up "Takotsubo cardiomyopathy" Hopefully what you were after. Stay safe, Camulos

I understand that is the point they were making and I still strongly believe that approach is WRONG!!!! Please tell me you check your pt's even if your monitor shows what are interpreting as VF/Asystole etc. I've seen VF looking rhythms that were caused by interference, I've seen asystole looking rhythms caused by leads falling off, in fact I've seen a whole host of spurious ECG rhythms caused by a multitude of factors. Whether you use "signs of life" or a pulse check, please check your pt's despite what the monitor may show. Come on, this is so basic!!!! Surely EMS has progressed beyond this??? Didn't I say exactly this in my second paragraph???? LOL Stay safe, Camulos

I hadn't heard of the rad 57 and thought the earlier supplied CO level was an air reading done by the fire dept which didn't tell me anything about the pt. I have since looked it up and must say "Can I have one please mummy?" - I love new toys. Would still like some comment on ? serotonin syndrome (SS) and whether that was actually investigated in hospital. I thought it may have been induced by opiates as was initially suspected by the EMS team. However I note urine tox screen was negative for opiates. Still does not rule out SS though as it can be caused by a combination of many other meds that pt's with a bipolar diagnosis may be on. Would be great to hear the end of the story if possible. Stay safe, Camulos

Don't know how useful this info is with protocol restrictions and all but you can use an 18G needle in a neonate in place of an I/O needle if necessary. This is commonly done in NICU according to my wife who is both NICU and PICU trained. I have no experience with this though and she has only ever seen it in hospital. Stay safe, Camulos

From a prehospital perspective there are many differential diagnoses here for me to even contemplate. Yeah let's get a BSL as that is easily reversible if it is the cause of the agitation. Apart from that I would restrain him. Physical restraint may make this situation worse hence my preference would be chemical in this case, high flow 02 with airway control if mandated, trip to ER and wish them luck. Given he was in a fire I would also have a low tolerance for sending him, and the other pt, to hospital due to the possibility of delayed onset pulmonary edema in such cases. I guess it's all about CYA. In hospital the management of this pt becomes a bit trickier. All the standard bloods, scans etc that these pt's usually mandate however the one thing I would want to rule out quick in this particular pt is serotonin syndrome - given the history of bipolar, agitation, recent admission with ? change of medications and the degree of hypertension. Mind you the clinical picture does not completely fit here as these pt's normally exhibit tachycardia and dilated pupils - neither of which this pt had. Temp may be a clue here also as these pt's can be profoundly hyperthermic. Would also be keen to know what this guy was cooking on the stove if we can determine that. Stay safe, Camulos

LOL I assumed catheters meant IVC's. Maybe not. He He Stay safe, Camulos

I'm sure you'll make a fine husband for the animals. Cya and stay safe, Camulos

I would be interested to hear your theory on why the glucometer was included. Stay safe, Camulos

I only need two things supplied which are essential to every shift - Doughnuts and a playboy magazine. LOL Seriously though I'm gunna choose; 1) PPE 2) O2 3) BVM 4) Defib / Monitor 5) Medication kit 6) Triangular bandages Perhaps it may be easier to just go to a different service!!! Stay safe, Camulos

Nah I still treat pt's 100% of the time. Those damn monitors are far too hard to cannulate and intubate for me to treat them effectively - LOL. Monitoring certainly dictates your treatment algorhythm during confirmed cardiac arrest. However should monitoring take over and negate pt assessment? I think not and believe that there is great danger in advocating there is "no point in doing pulse checks until you see an organised rhythm on the monitor" - as was suggested. In examining whether this approach is appropriate I would appreciate if anyone could answer this question. Are there any "disorganised" (your term, not mine) rhythms that can generate a pulse? Stay safe, Camulos

1) Evidence based research 2) Post it on emtcity.com and hope the EMS ppl run with it. Stay safe, Camulos

I certainly hope none of your ECG leads are inadvertantly dislodged without you noticing. I personally prefer to treat pt's rather than monitors. I question the validity of checking pulses during CPR to determine the effectiveness of cardiac compressions. During compressions the retrograde transmission of pressure through the venous system may give the perception of the palpation of pulses in the adjacent artery and may not be a sign of forward flow. This is the "venous pulse" that BEorP was referring too earlier. In that sense I don't know that checking for a "pulse" as a sign of adequate compressions is beneficial because I feel it is not clear what you are truly assessing. Stay safe, Camulos

There’s redness and then there’s redness. A small degree of redness may be considered normal and is usually localised to only a small diameter around the actual insertion site. Redness of this nature is not normally of cause for concern for me. In the original scenario however I note that the “leg was turning red”. Widespread redness covering an entire leg, or vast majority thereof, would definitely cause me concern as it would greatly raise the suspicion of fluid / drug extravasation. In a child this small, such extravasation can be devastating and could even result in loss of limb if large enough. It is also not uncommon for neonates to have clotting abnormalities. As I didn’t see it do you believe the redness could have been bleeding? Despite the actual cause, and even though there was a lack of associated swelling, I would be keen to get this line out ASAP. I doubt x-ray would offer me much in this situation. Even if the x-ray confirmed the line was in the correct position, I would still be keen to remove it due to the degree of redness described. I also note that the “I/O was firm”. In neonates you may not get the “firmness” that you would normally expect with older children and adults due to their relatively pliable bones. I have also found that IO lines typically run better under pressure. In neonates however we don’t run fluids in this manner as everything is syringed in so as to ensure accurate weight based doses. Lastly a question. Would re-aspiration of marrow be considered appropriate once fluid has been infused into this line? Stay safe, Camulos

Looks like a rhythm strip to me. Jokes!!!! I agree with fiznat - SVT with aberrancy - probably a RBBB due to the deep S wave. Would need a 12 lead to assist with confirmation though. Stay safe, Camulos - The member formerly known as Curse

Hey LyonN, Welcome to the forums!!! I hope you get a lot out of them and learn a lot - as I have certainly done. I disagree that MAT and A-fib are the same thing. I'm sure if you go back and look at the diagnostic ECG criteria for the two you will see the distinct differences between them. That would certainly save me a bit of typing however if you would prefer that I outline the specific differences here just let me know and I'll hit the keyboard. Stay safe, Curse

The pt’s with laryngeal fibrosis that we nasally intubate are not candidates for a surgical airway. We see quite a few of these at the hospital I work at due to our proximity to a nearby regional cancer centre. These pt’s have stiff, immobile larynx’s and our hospital ENT team will not go near them with a surgical airway so far be it for us to from an anaesthetic / ICU point of view. Mind you, these pt’s are not intubated for TREATMENT of their laryngeal fibrosis per se but for other reasons associated with their often fragile state of health. We, as with any pt, aim to pull the tube out ASAP, however sometimes that just is not possible and if we anticipate a prolonged intubation in one of these pt’s we prefer the nasal route as it seems better tolerated during the conscious weaning phase. There are sometimes advantages in intubating pts whilst still awake as loss of a spontaneous airway from RSI can cause more potential difficulty than benefit. Some of these pt’s will be immediately sedated once the airway has been secured, some will not – it depends on each individual case and what our treatment goals are. As for intubating pt’s with altered anatomy due to facial surgery I’m talking more about mandibular/ oral abnormalities that may make the oral route difficult or near impossible. As far as NTI I DO NOT do this BLINDLY in the hospital as keeps getting suggested. I don’t mean to seem as though I am shouting here however I have mentioned this on several occasions in previous posts and it seems to be getting missed . ALL NTI’s I have done in hospital have been FIBRE OPTICALLY ASSISTED and not done blindly. I have only done one blind NTI and that was pre hospital – unfortunately my fibre optic gear just didn’t fit in my kit that night. I am very cognisant of the advanced technology available in hospitals to assist with intubation. However sometimes, even with that technology, orotracheal intubation is just not possible. When this is the case you have to decide between surgical and nasal. If it is your preference to provide a surgical airway in all of these cases then so be it – I just hope you can justify it. However I personally do not take the decision to use a surgical airway lightly and have managed to avoid it by using NTI on many occasions – and I can justify my reasons for each one of these cases. Mind you, sometimes the indications for surgical airway are clear and if so you have to escalate to that level immediately. Don’t get me wrong here. I don’t go around sticking tubes in pt’s noses preferentially. Oral is BY FAR preferable – I have stated that before. However I also feel that sometimes nasal offers advantages over a surgical airway when the oral route, for whatever reason, is not possible. I understand the research that is out there regarding NTI. However the research does not say that NTI is completely outdated as I feel you are suggesting – outside the OR anyway. There are obvious risks, I am aware of these and have stated that numerous times previously. Sometimes these risks are an accepted part of the procedure we are adopting, sometimes they are not. It would be like saying that no pt should EVER be intubated orally as this also causes sinusitis which can lead to VAP. However in deciding to intubate someone orally we recognise and ACCEPT this because the benefit of the tube is greater than the associated risk. As I keep saying it is risk v’s benefit. And that is the challenge for us as clinicians – to evaluate this balance and decide what is BEST for our pt’s. Mind you we don’t always get that assessment right and hindsight can sometimes come and bite you on the ass. If you insist on wanting to know what I am and what position I am in I'll tell you. I am a human (I hope) and I am currently in the Savasana position - I love Yoga!!! Stay safe, Curse

Sorry for the late reply, I had to pull a few night shifts down at the NTI clinic. Despite my credentials being questioned MANY times, I don’t believe I questioned anyone’s credentials and would appreciate an example of this. To be entirely honest I don’t care for anyone’s credentials on here. It doesn't bother me how much experience someone has, how many conferences they have been to or spoken at or indeed what they do for a job. I’m more interested in what they have to SAY. Having said that you are otherwise completely correct and I am more than happy to get back to the facts. I feel chbare is the only one that really gets it so far. A lot of what we have said is not disputed. The original statement that I disagreed with was “The ONLY time it is acceptable at many hospitals is for special facial surgeries where a RAE tube might be used”. I am wary of using words like only, always, never, when it comes to treatment options in medicine as I feel it does recognise, or at least limits, individualised care. I am certainly not immune to using these words at times though and ALWAYS catch myself doing it – DOH, Did it again!! If many hospitals ONLY utilise NTI for special facial surgeries then so be it – it doesn’t bother me. However I still believe that NTI is a treatment option that should be considered in certain circumstances that extend beyond the operating room. Times where I have personally used this emergently in the past have included; • Altered anatomy due to previous facial surgery • Retrunded mandible – eg. Arthritis, ankylosing spondylitis • Alert, conscious pt's in whom RSI may cause more potential problems than benefits • Pts with laryngeal fibrosis secondary to radiation that may require a period of prolonged intubation as it has been our experience that it is usually better tolerated than an oral tube. I have not seen much of a need to do blind nasal in hospital and indeed have not personally utilised this practice in this setting as all nasal tubes have been visually assisted, as I stated earlier. The main point I am highlighting is that although NTI is not as prevalent as it once was, I believe it would be sad to completely wipe it off your list of options when considering airway management outside the OR. It has certainly helped me out in certain circumstances beyond the operating room in avoiding the need for a surgical airway. If you ONLY use NTI in the OR then go right ahead – you obviously have your reasons. But please don’t denigrate me or my hospital, as was done, when we use it outside the OR when it is indicated and provides the best option available THAT time. I guess it is sometimes just a matter of agreeing to disagree - perhaps this is one of them. Stay safe, Curse PS – Please tell me "idiots guide to ventilators" is not really a book!!!

You have made very broad statements and assumptions about hospital practice. Where?? Examples please. Where and how have you studied ventilators in the ICU? Where - In a hospital (ICU and anaesthetics) to be exact How - Experience, research, text books, idiots guide to ventilators etc Or worked extensively in ICU which if you have and do you would not be questionly VAP issues and ventilators. I never questioned the association between ventilators and VAP. Read again - I asked where sinusitus has been proven as a causative factor in VAP. This is one subject I rarely joke about since it is my specialty and I have seen the consequences of what happens when people don't understand ventilators, tubes or meds such as paralytics. I joke often. Why not - it worked for Patch Adams right? He even got his own movie!!! I wonder who will play me in my movie? Shame John Candy is no longer with us. I could take time to give you individual links or spoon feed you as I do for some in EMS but you stated you know how to search. I'll only take spoon feeding if you tell me it's an aeroplane and make it fly into my mouth. And who said I was EMS?? If you really insist on a bunch of individual links I can post and I many anyway later as those that know me here usually expect to see my latest data I thought you didn't need the data?? You stated you have your first hand experience with your pt's. Over 10 years ago, we may have seen 10% or 10 out of 100 ventilator patients in the adult world with NTI. Now, it will only be seen from the OR for specific surgeries that will not be intubated for more than 48 hours. There is a big world outside your hospital. I still know how to do NTI but prefer not to if at all possible. Me too!! I also see those that get shipped to my hospital for specialty ventilation and reconstructive surgery as the result of NTI or mucked up ventilator management. Me too!! I also see those that require nasal antibiotics long term and those that need dialysis from long term IV antibiotic use. We don't routinely give the AB's nasally and more commonly administer them systemically. And I hate dialysis. I'm going to bed. My brain hurts!!! Stay safe, Curse

Wow! You have managed to try to make this a pissing match. I bet mine goes futher than yours!!! Just jokes, no pissing match. I'm just highlighting what I feel are important points. Have you studied the various methods of ventilation in the ICUs extensively? Yes Do you know how ventilation and oxygenation practices have evolved? Yes This is not about getting "gold stars" but improving the ways of medicine for advancement. Long term paralytics are not longer used extensively in the critical care units. I really don't see a need for sarcasism if you disagree. I agree long term paralytics are no longer used as extensively as they were in the past. I never disagreed. More gold stars for everybody. However, I would like to know why you disagree about the long term use of paralytics and prolonged vent days. Huh?? When did I state this???? I don't have to rely just on articles since I have has first hand experience with NTI and the patients. I thought you said your employers mandated that you keep up to date with the current articles??? And what first hand experience do you have of NTI considering this earlier comment of yours "I honestly can not remember resorting to a nasal intubation in or out of hospital in 15 years at least." Certainly not recent experience that's for sure. The articles you pulled up are from European sources and pertain to specific situations in the OR which I have already said the RAE tubes are used for NTI when the vent days will be limited. It is difficult to compare a few cases requiring such intensive knowledge of intubation in special precedures with what is done everyday in critical care units. Yes, case studies are abundant and it is important to understand these as well. However, I am talking in broad accepted practices and not the rare ones which can be successfully implimented in common practice in the many ICUs across the country. Seems a lot of people are going to a lot of trouble to study such a rare event. It didn't take you long to read ALL these articles. Whilst some do concentrate on the OR setting some do not. These articles were actually just the most recent one's published on NTI to highlight the incorrect statement that there was not much current info out there. I also see you have wasted alot of time finiding articles about the rare situations instead of looking at what is accepted practice in the United States. There is a big world beyond your shores. I think you could have an easier time researching the correlation between sinusitis and lung infection. But, let me help you out: (multiple pages) http://scholar.google.com/scholar?q=VAP+si...p;hl=en&lr= Have not read through all these however certainly do hope they answer my specific question on exhibiting the causality between sinusitis and VAP. If so, as I said, I am eternally greatful. Here is a good link to help with your search if you don't have access to a good medical search engine. http://scholar.google.com Thanks for that. I have work ones that are very useful and would love to share them however they are unfortunately password protected. Again, I am not talking about "sticking holes in necks" (your words) as done emergently in the field. Please try to see the difference between this emergency procedure and a tracheotomy or tracheotomy that is done in the hospital to facilitate weaning and give them back their voice. Definitely see and understand the difference between field and hospital surgical airways. However, as crude as it sounds, it is still a hole in the pt's neck. Of course if you are implementing "holeless" trachies I'm coming over to learn this technique. Also, do not confuse the "holes" with the stoma made for laryngectomy patients. Those are very different as is their purpose. Would never confuse them. When I was a kid my uncle had a laryngectomy. It used to absolutely freak me out. Actually most of them still do these days!!! Stay safe, Curse

Have you even been nasally intubated? No You will not find much current information about NTI since it is no longer accepted in the hospitals except under rare circumstances. Please see; Sugiyama, Kazuna DDS, PhD; Takahashi, Naoki DDS, PhD; Kohjitani, Atsushi DDS, PhD The EndoFlex® Tube Enhances Navigability Through the Nasal Cavity During Nasotracheal Intubation. Anesthesia & Analgesia. 108(4):1358-1359, April 2009. Lallo, Alexandre MD, FRCPC *+; Billard, Valerie MD *; Bourgain, Jean-Louis MD * A Comparison of Propofol and Remifentanil Target-Controlled Infusions to Facilitate Fiberoptic Nasotracheal Intubation. Anesthesia & Analgesia. 108(3):852-857, March 2009. Kitagawa, H.; Sai, Y.; Tarui, K.; Imashuku, Y.; Yamazaki, T.; Nosaka, S. Airway Scope®-assisted nasotracheal intubation. Anaesthesia. 64(2):229, February 2009. Muallem, Musa; Baraka, Anis The use of the GlideScope to facilitate nasotracheal intubation: in patients with a difficult airway. European Journal of Anaesthesiology. 26(2):179, February 2009. Sharma, Rajeev MD; Kumar, Rakesh DA, MD; Kumar, Sunil DA; Gupta, Neera R. MD Connector Assembly to Improve Performance of the Lighted Stylet (Trachlight) for Nasotracheal Intubation. Anesthesia & Analgesia. 107(6):2095-2096, December 2008. XUE, FU SHAN; Luo, MAO PING; LIAO, XU; ZHANG, YAN MING Lightwand guided nasotracheal intubation in children with difficult airways. Pediatric Anesthesia. 18(12):1276-1278, December 2008. MONCLUS, ENRIC MD; GARCES, ANTONIO MD; ARTES, DAVID MD; MABROCK, MAGED MD Oral to nasal tube exchange under fibroscopic view: a new technique for nasal intubation in a predicted difficult airway. Pediatric Anesthesia. 18(7):663-666, July 2008. Note the oldest article here is from July 2008. Does that count as recent? There certainly seems to be an abundance of rare circumstances occurring and I can keep going if required but don't want to bore people. The way we venitilate patients have also changed. We no longer paralyze and sedate for 7 days and then trach. We try to get patients off the vents in as few days as possible. Good on you. So do we. Gold stars all around!!! To say NTI is more comfortable is in the same ball park as saying babies don't feel pain which was the reason for doing surgery without sedation for many years. I think medicine has advanced enough to move on from some of the old "traditions" and ways of thinking. I personally don't get this comparison and for the record definitely think babies feel pain. It used to really hurt when I was continually dropped on my head as a baby!!! Perhaps that is my problem - LOL. NTI is frequently documented as being better tolerated than oral tubes on awake pts - both during insertion and afterwards. Come on - I'm sure you have read this or do I really need to provide some links for this also? A trach done in the hospital in not like the ones done in the field. Agreed. Put me in a hospital any day over a dirty paddock to be performing surgical airways. I am talking about critical care medicine. You need to see a broader view. I believe I do have the broader view as I am not the one saying that nasotracheal intubation is outdated and only rarely performed. My stance on NTI is because I have done this for a long time and have participated in the research that has gone into making the guidelines. Excellent!!! I have wanted to question someone who has made these guidelines so am cherishing this chance. I preferentially choose oral over nasal intubation in most circumstances - as suggested in the guidelines and I also stated earlier. However my understanding of the guidelines, and correct me if I am wrong, is that NTI is not preferred due to its increased association with ventilator associated pneumonia (VAP) secondary to tube induced sinusitis. However what does seem to be lacking in the guidelines is the actual research that exhibits causality between sinusitis and VAP. As you have participated in this research I'm sure you can provide these findings and when you do I shall be eternally greatful. I do stay current with the medical literature because that is an expectation of my employers. I hope the above references assist you in this task as it seemed you may have been unaware of these by your earlier comment of not finding much current information about NTI. It could be said you have an adversion to trachs when they have been around for centuries. Example please. When a surgical airway is indicated I perform them. However I certainly don't go around sticking holes in pt's necks willy nilly without seeking possible alternatives. One of my closest friends is a neurosurgical trainee - I should tell him that burr holes have also been around for centuries and therefore he can get his drill out even before the CT scan in future. I could go all night but as I said earlier don't want to bore people - (Get the pun??) Stay safe, Curse

As I said, it is rarely an ideal first choice airway. However it can be of benefit when it is indicated. I am not advocating that all pt's should be nasally intubated however nasotracheal intubation is definitely another option in the list airway strategies that can, and have, been beneficial to pt's. As I also said before, it is not without it's risks, which I am very cognisant of. These of course must be weighed up in the decision making process and again as I said earlier it can sometimes be a difficult decision between nasal v's surgical airway. I disagree that nasotracheal tubes are not more comfortable. There is a whole host of anaesthetic literature outlining that nasotracheal tubes are usually better tolerated than orally inserted tubes. This has certainly been my anecdotal experience also. Increased work of breathing is one POTENTIAL disadvantage of NTI due to the smaller tube that has to be inserted. In the short term this is usually not much of an issue and long term can certainly be minimised, or overcome, with good ventilator strategies. I understand you are quite passionate about not using NTI however I would hope you don't completely wipe it off your list of possible options when considering airway management. There are cases when it provides a good alternative and doesn't mean a large hole and scar in some poor pt's neck. Stay safe, Curse

Nasal intubation is rarely an ideal first choice airway however does offer advantages when it is indicated in a hospital setting. Some advantages include; * Surgical field avoidance - cases include dental procedures and certain maxillofacial surgeries - particularly of the mandible when wiring is utilised. * Poor oral access - eg. Arthritis and ankylosing spondylitis (my only prehospital case) * Inability or difficulty in elevating the epiglottis * Prolonged ventilation - where the nasal route is often more comfortable. Despite these advantages it can sometimes be a difficult decision to decide between nasal v's surgical airway when the oral route is not an option. It should also be kept in mind that the inhospital procedure is not usually done blindly and more often involves fibreoptic assistance in order to facilitate the insertion. Stay safe, Curse

Whilst nasal intubation can offer many advantages in a hospital setting, I personally find the practice of limited value in the pre hospital arena. I am however lucky enough to have the option of RSI and surgical airway capability and recognise that my decision may be different if this were not so. As an emergent pre hospital airway I have only ever utilised blind nasal intubation (BNI) once. This was on a pt with ankylosing spondylitis who presented a very difficult airway challenge. But that is another story and shall be told another time. Without the ability to use RSI or provide a surgical airway, BNI may be a potential alternative – particularly in the case of trismus that was mentioned by the original poster. BNI is of course not without its disadvantages and difficulties though. BNI certainly has a higher complication rate, cannot be used in the apnoeic pt, is more traumatic and is less frequently successful. In this sense one should obviously use BNI with caution and as always the benefits should outweigh the risks. I note some earlier replies on this topic mentioning BOS # as a contraindication is outdated. However I cannot determine if they are only referring to nasopharyngeal airways (NPA)or nasotracheal tubes (NTT). I recognise the risk of NPA is “probably” low given their flexibility however feel that the same cannot be said of NTT. BOS # is certainly still on my contraindication list for pre hospital NT intubation and I believe rightly so. Whilst it is true that the actual incidence of cerebral NTT is low , I would hazard using this statistic as a reason for advocating that clinically evident BOS # is an outdated contraindication. Perhaps the low incidence is due to the fact that EMS providers have been correctly following the guidelines and not inserting these tubes when the clinical signs of basilar skull # are evident. In that sense, the low incidence is a measure of the success of BOS # being a contraindication and would support the continuation of this practice rather than refute it. I also believe that although the actual incidence of cerebral NTT’s is low we cannot extrapolate that the RISK of this procedure is also low. In order to assess this we only have to look at the many case reports, and x-rays such as that kindly provided by Mobey, of nasogastric tubes that have been cerebrally placed. As BOS # has been an established relative contraindication for some time, I believe the impetus here should be to disprove, rather than prove, this practice in order to effect change. That of course, I imagine, would be hard to do however if there is something out there I would be more than keen to hear about it. It would be great to hears others actual experiences with BNI – both good and bad. Stay safe, Curse