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The problem is, you don't know that you can manage the failed airway until you've already successfully managed it.

Very true mate, I've heard the average "cant intubate, cant ventilate" encounter for an anaesthetist is two or three times in their entire career. You can reduce your risk with a good pre-intubation assessment and back up plan as well as plenty of experience. This is why we restrict RSI to a select group of upskilled Intensive Care Paramedics so it is tightly controlled and has a high rate of utilisation per Officer.

For Ambulance, the risk of a "cannot intubate, cannot ventilate" situation may be slightly higher; people with massive facial trauma etc.

In nearly ten years we have a 3% failure rate of RSI and all have been managed without cricothyrotomy

Absolutely, and early intubation is a classic paramedic mistake. But some asthmatics will need intubation. If they cant breath for themselves, someone else is going to have to do it, or that cardiac arrest is going to be just as inevitable.

Early intubation for some people is a good idea; for patients with severe multi-system trauma, traumatic brain injury, unconscious with poor airway of whatever aetiology etc

I am quite interested in the use of prehospital RSI of patients who have severe trauma but do not have traumatic brain injury. Such people might included people with amputated limbs or multiple severely fractured long bone but that's for another discussion. I notice the Doctors on London's Air Ambulance often do this.

As for the asthmatic patient; again if we've got a prolonged transfer of a very sick asthmatic then I might consider it

Hypeventilation is an issue. But this is why we should be giving smaller volumes less frequently. With a nicer ventilator you can worry about airway pressures.

Yes, we ventilate an asthmatic at six breaths per minute and have had a big push on to get people to understand the problems of hyperinflation and the seriously bad ju ju that brings

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Very true mate, I've heard the average "cant intubate, cant ventilate" encounter for an anaesthetist is two or three times in their entire career. You can reduce your risk with a good pre-intubation assessment and back up plan as well as plenty of experience. This is why we restrict RSI to a select group of upskilled Intensive Care Paramedics so it is tightly controlled and has a high rate of utilisation per Officer.

Out of curiousity, do you know how often the average ICP intubates with RSI a year? And without? And I mean, actually holding the laryngoscope, not just being there while someone else does it? I'd just be interested to see the numbers, if you have them, and are allowed to share.

For Ambulance, the risk of a "cannot intubate, cannot ventilate" situation may be slightly higher; people with massive facial trauma etc.

I think so. I think the average prehospital intubation is likely more challenging that the average ER intubation, and not just because the providers are less skilled and have less options for backup. There's been at least one publication on this, but I can't remember the details. One of the problems with this area is that there's often an inconsistency between what we consider to be a difficult airway, or how we grade airways, compared to how physicians do it. Although balancing that, there's often a tendency to report intubations as being less traumatic or complicated than they actually are.

In nearly ten years we have a 3% failure rate of RSI and all have been managed without cricothyrotomy

That's fantastic. Have all the patients requiring surgical airways been managed without RSI? Or have there been no patients requiring cricothryrotomy at all?

Early intubation for some people is a good idea; for patients with severe multi-system trauma, traumatic brain injury, unconscious with poor airway of whatever aetiology etc

I am quite interested in the use of prehospital RSI of patients who have severe trauma but do not have traumatic brain injury. Such people might included people with amputated limbs or multiple severely fractured long bone but that's for another discussion. I notice the Doctors on London's Air Ambulance often do this.

I think there's so much focus on closed head injury because those patients have been shown to be so sensitive to hypoxia, hypercapnia, hypoglycemia, transient hypotension, seizure activity, etc. so it makes sense that this is where the biggest improvement, but also the biggest risk is. It seems like there's been relatively little focus on the safety of intubating medical patients prehospitally using paramedics.

I think the need to paralyse is reduced in patients without trismus, and in hypotensive patients, but it provides better intubating conditions (or at least should).

As for the asthmatic patient; again if we've got a prolonged transfer of a very sick asthmatic then I might consider it

Yeah, I definitely don't want to come across as suggesting that we should be running around tubing COPDers and asthmatics just because they're a little sick. But there is this point where they're not responding to medications, started to get tired and acidotic, and there's this window of opportunity to intubate them where you're going to have some sort of half-decent SpO2 for a short period of laryngoscopy, at least. I think if we had better ventilators for doing bilevel ventilation, we might be able to avoid this happening even more often.

If there's a real hospital close, it makes sense for the patient to be intubated by someone with a lot more skill and familiarity, in an environment where help is readily available.

Yes, we ventilate an asthmatic at six breaths per minute and have had a big push on to get people to understand the problems of hyperinflation and the seriously bad ju ju that brings

Do your ICPs work as pairs, or do they respond individually? Just wondering. Do the ambulance paramedics do any form of narcotic / benzo / anesthetic facilitated intubation, e.g. drug overdoses, etc. Do they have the ability to cric'? I'm just interested as to where one scope ends and the other begins. If you have any links, I'd love to read them.

It sounds like the NZ system is very well structured.

Edit: quote tags

Edited by systemet
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Out of curiousity, do you know how often the average ICP intubates with RSI a year? And without? And I mean, actually holding the laryngoscope, not just being there while someone else does it? I'd just be interested to see the numbers, if you have them, and are allowed to share.

Last I heard was median is just over one RSI per week

Without RSI I'd take a guess and say maybe each Intensive Care Paramedic intubates a dead person maybe once a month? It might even be less and it would not surprise me if it were.

Since 2009 we've been actively discouraging ALS people from intubating without medicines as the mortality rate does not appear to be changed by intubation and if a well working LMA is in place then why change it over?

Have all the patients requiring surgical airways been managed without RSI? Or have there been no patients requiring cricothryrotomy at all?

No failed RSI patients have required cricothyrotomy

A "failed" RSI here is extremely rare (2-3/100) and a "failure" here is defined as

- unsuccessful after two attempts at intubation, or

- unable to visualise cords within 15 seconds of laryngascopy, or

- unable to intubate within 30 seconds of laryngascopy,

is. It seems like there's been relatively little focus on the safety of intubating medical patients prehospitally using paramedics.

We can RSI patients with "poor airway and/or breathing" who have a GCS of less than 10 be it of medical or trauma aetiology. Most of our RSI patients seem to come from trauma, but others include post cardiac arrest, stroke, poisoning, pulmonary edema etc

I think there is also a role for anaesthetising and intubating the multi-system or severe trauma patient who does not have a poor airway or breathing in selected circumstances where otherwise gaining adequate analgesia to enable the patient to be treated and transported is going to be very, very difficult. Again this is something that the Doctors on London's Air Ambulance do now and again it seems.

Do your ICPs work as pairs, or do they respond individually? Just wondering. Do the ambulance paramedics do any form of narcotic / benzo / anesthetic facilitated intubation, e.g. drug overdoses, etc. Do they have the ability to cric'? I'm just interested as to where one scope ends and the other begins. If you have any links, I'd love to read them.

Our Intensive Care Paramedics respond individually, you may get two ICPs at a job but it's certainly not common unless the patient is very unwell or heavily trapped.

Here's what a Paramedic vs. Intensive Care Paramedic can do

Paramedic

OPA, NPA, LMA, PEEP, tourniquet, 12 lead ECG interpretation, defibrillation, cardioversion, NaCl 0.9%, aspirin, GTN, salbutamol, ipatropium, glucagon, 10% glucose, ondansetron, loratadine, entonox, methoxyflurane (where used), paracetamol, adrenaline, amiodarone (cardiac arrest), ceftriaxone, morphine, fentanyl, midazolam (seizures), naloxone

Intensive Care Paramedic

Paramedic + intubation, intraosseous access, cricothyrotomy, chest decompression, pacing, atropine, adenosine, amiodarone (fast AF or VT), ketamine, midazolam (sedation), vecuronium*, RSI (selected Officers only)

* All Intensive Care Paramedics can sedate and paralyse an already intubated patient (i.e. dead person) but only selected RSI trained ICPs can anaesthetise and paralyse to intubate, the difference is subtle but important.

It sounds like the NZ system is very well structured.

Well, we are pretty awesome, now if only we could convince the Ministry of Health to give us more money!

Edited by kiwimedic
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Well, we are pretty awesome, now if only we could convince the Ministry of Health to give us more money!

Kiwi....

you can think your awesome...........

come to the great land of Auz

dollar exchange is 1 Aus to around 1.30 NZ and 1.07 US that way you will get more money.......

and i got around 100K last year before tax....and it's better here (just ask the millions of other kiwis living on our shores)

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  • 2 weeks later...

I'm an asthmatic. In all honestly when my asthma gets so bad I start getting tired out I welcome any assistance. On the other hand if you came at me with a tube and didn't knock my ass out first I'd start swinging! Just my two cents.... :)

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I'm an asthmatic. In all honestly when my asthma gets so bad I start getting tired out I welcome any assistance. On the other hand if you came at me with a tube and didn't knock my ass out first I'd start swinging! Just my two cents.... :)

I am curious, have you ever been intubated for asthma or have you been in hospital more than twice in any one year for asthma?

Ketamine is actually the preferred induction agent in asthmatics due to its bronchiodilatory effect but, intubating an asthmatic can bring on a lot of bad ju ju as I've commented elsewhere at length about. It's something with a very fine line between help and hurt.

Edited by kiwimedic
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I was hospitalized a few times last year with my asthma and once for a bee sting (allergic). Haven't been tubed yet but it's come close to it. I finally got on meds that reduced my symptoms by quite a bit so we are aiming for no hospital visits this year for me (except for taking my patients in, of course). :)

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I was hospitalized a few times last year with my asthma and once for a bee sting (allergic). Haven't been tubed yet but it's come close to it. I finally got on meds that reduced my symptoms by quite a bit so we are aiming for no hospital visits this year for me (except for taking my patients in, of course). :)

I hate to say it, but two or more hospitalisations in a year for asthma put you at an increased risk of death from asthma (as would previous intubation for asthma)

Glad to see you got your asthma under control :)

Bloody asthma plans and patient education, the rate of life threatening asthma has dropped off quite a bit here it seems ... what happened to the good old days?

Edited by kiwimedic
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oh yes, I am all well too aware of that fact and I was the one who pushed for my docs to find something to control my asthma. I always carry my inhaler and epi pen with me because I am not taking ANY chances! :)

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