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Forcing the Tube


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That sucky feeling changed something in you and you changed your practice. That's why these things happen, so that we can learn from them.

Bieber I personally think you are on the right track. Sounds to me that you are progressing well as a young practitioner. I always wanted my students and new medics to ask these types of questions. Wh

I am really hoping by these statements that your "on the rag again" I know that it is hard to armchair this but in my experience respiratory arrest secondary to COPD is not a death sentence. I have pe

Just curious, My brother lives in VA Beach and works in Norfolk... He just retired from the Marines

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As a student you belong in this conversation as much, or even more so, arguably, than anyone else. Good on you for having the balls to jump in.

A couple of questions Mr. student man... :-)

Mobey mentioned that his rationale for intubation was patient exhaustion. And I completely agree with that now, after his explanation, so assisted ventilations at a minimum would seem manatory, right?

I also thought that bagging was a viable option, and bagging in a neb treatment even more so. But lets assume the transport time is 5 minutes. Do still feel the same? How about 30 minutes? 60 minutes?

Does your feeling on maintaing this patients ventilation status change in each scenario? What might the issues be should you choose to bag in each instance instead of intubate?

I haven't noticed you posting for a bit...good to see you here!

A friendly note to you, and others...simply for the ease of reading, paragraphs help. I sometimes, and I know others do as well, simply pass up posts that are in a giant block. Though sometimes you end up breaking parahraphs in illogical places, reading in pieces is much easier online.

Dwayne

Edited to correct spelling errors only.

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We just got Versed here where I am in college for my rotations and our new protocols should be out in the next couple months. Luckly you can hook up a neb to a bvm without much problems as long as you have the T connector and the neb tube and connect it from the BVM to the mask. We do not have decadron here but we do have solumedrol. I am hoping to see that when the new standards for the scope of practice take full effect that it will open up new horizons for our protocols especially for these types of patients so our hands aren't tied up with this situation.

I hope you are not planning on using versed alone for RSI, are you stating that you will just use it for those who fight the tube, after intubation ?

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Dwayne, absolutely I would agree on transport time. If arrival at hospital is ten minutes I will assist with BVM, but for me if I am 40 minutes out I will consider intubation. We do not RSI but I might have used versed as an adjunct in the way this patient presented.

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HLPP, could you present a similar situation where you have had to weigh risk/benefit in airway management. With all do respect I have read your posts and am under the assumption you are a non-emergency transport service. Sure the risk is there for a potential non-emergent situation to turn emergent.

I have scenerio I will present and please others weigh in on this one cause it still haunts me. MVC ejection. Both your air medicals tied up. Trauma center 45 min out. No obvious external injuries. Pt gcs of 5, unequal pupils (one blown), patient showing Cushings Triad symptoms. Airway suction needed. No vomitus (yet), pt has clenched jaw. Your attempts at sunctioning are minimal, you are able to pass the catheter through an approximately 2-3cm opening, this opening could allow you to pass a laryngoscope, but would in no way allow you to visualize the cord. How would you manage this airway? You do not RSI. Your prayers to meet up with medivac go unanswered. Patient begins to vomit large amounts of chunkyness.

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Hey guys, thanks for all the responses. I'll start replying to them by tomorrow or something. Had surgery to get my last wisdom tooth out today, so I'm not a hundred percent. Great conversation, though.

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HLPP, could you present a similar situation where you have had to weigh risk/benefit in airway management. With all do respect I have read your posts and am under the assumption you are a non-emergency transport service. Sure the risk is there for a potential non-emergent situation to turn emergent.

I have scenerio I will present and please others weigh in on this one cause it still haunts me. MVC ejection. Both your air medicals tied up. Trauma center 45 min out. No obvious external injuries. Pt gcs of 5, unequal pupils (one blown), patient showing Cushings Triad symptoms. Airway suction needed. No vomitus (yet), pt has clenched jaw. Your attempts at sunctioning are minimal, you are able to pass the catheter through an approximately 2-3cm opening, this opening could allow you to pass a laryngoscope, but would in no way allow you to visualize the cord. How would you manage this airway? You do not RSI. Your prayers to meet up with medivac go unanswered. Patient begins to vomit large amounts of chunkyness.

I seriously doubt midaz will a)release the neurologically caused trismus and b)do anything but screw up your CPP if given in adequate amounts to release the trismus. In the scenario above I'd be holding a scalpel if RSI wasn't available.

Pharmacologic airway control should be an all or nothing proposition. Using sedatives only increases aspiration risk and sets up the can't intubate/can't ventilate scenario. Either your good enough to use it all, or your not. Halfassery has no place in airway management.

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...I have scenerio I will present and please others weigh in on this one cause it still haunts me. MVC ejection. Both your air medicals tied up. Trauma center 45 min out. No obvious external injuries. Pt gcs of 5, unequal pupils (one blown), patient showing Cushings Triad symptoms. Airway suction needed. No vomitus (yet), pt has clenched jaw. Your attempts at sunctioning are minimal, you are able to pass the catheter through an approximately 2-3cm opening, this opening could allow you to pass a laryngoscope, but would in no way allow you to visualize the cord. How would you manage this airway? You do not RSI. Your prayers to meet up with medivac go unanswered. Patient begins to vomit large amounts of chunkyness.

You don't mention respiratory rate, but I'm thinking that you'll have to nasally intubate this guy. I understand the issues with the presenting closed head injury, but I don't see any real options here. Plus, you don't really mention anything that would imply basal skull fractures, and lastly, I think that many places now, like not medicating abd pain, are moving away from "No nasal intubation on head trauma."

Nose hose it is I'm thinking...or hang out for a few mins and he'll crump and be easier to manage...

But in the end...I know this call sucked. There's just no way around that...

Dwayne

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