🚀 go-pugleaf

do you use nasotracheal intubations in your system? in the system I am 
familiar with they have very high success rate with them, even in closed 
head and facial trauma. I know everyone has seen or heard of the 
intubated cranium, but do you know that it is the only case of this 
happening ever?

Lamont Cranston wrote:
> 
> do you use nasotracheal intubations in your system? in the system I am
> familiar with they have very high success rate with them, even in closed
> head and facial trauma. I know everyone has seen or heard of the
> intubated cranium, but do you know that it is the only case of this
> happening ever?

No first-hand knowledge of it ever happening, but like everything in medicine, I'm sure there was at 
least one poor sucker it happened to.

-carey

J.M. Douglas wrote:

> The B.C. Ambulance Service Advanced Life Support (ALS) Paramedics
> currently do not use a paralytic agent for rapid-sequence intubation
> for head trauma patients.  We have concluded from our preliminary
> research that a neuromuscular blockade agent can be used safely and
> effectively in the field by experienced paramedic teams. 

Hi:

Like you, we are not doing rapid sequence induction (RSI). Like you, our staff 
are interested in doing a needs assessment for RSI for our operation.

I would be interested in hearing from you about your investigation into RSI for 
EMA IIIs in BC. I will be in BC at the end of September, so I may give you a 
call if you don't mind.

FYI:

We have a "Facilited intubation" or "pre-intubation sedation" protocol. It 
reads as follows:

"In the instance when the Flight Paramedic determines that sedation is required 
to facilitate intubation, the Flight Paramedic will attempt contact with the 
Base Hospital Physician. If the Patch is impossible or cannot be obtained 
quickly, the Flight Patramedic may administer Midazolam 1-2 mg IV and/or 
Fentanyl prior to intubation and re-attempt the patch."

When intubation is indicated for the patient with a suspected or confirmed brain 
injury, a bolus of Lidocaine 1-1.5 mg/kg may be administered prior to intuation 
to blunt the effect of raised intracranial pressure."

In my experience, the facilitated intubation protocol has worked relatively well 
for many of our patients, with some acceptions where we've had to patch to get 
additional orders for Midazolam and/or Fentanyl. I would also say that we seem 
to have a significant number of patients, who in my humble opinion, would be 
better served by RSI intubation. As I say, we need to do a needs assessment to 
determine if in fact we have a sufficient number of patients who would benefit 
from RSI and if the numbers would be sufficiently high to maintain the skill.

I look forward to hearing from you.

Rob Theriault  EMCA, RCT (Adv., EMA III,
               Critical Care Flight Paramedic
Bandage 1, Dedicated Air Ambulance
Toronto, Ontario, Canada
E-Mail: rob.t@sympatico.ca
---------------------------------------------
Director of Education and Research
Ontario Paramedic Association

Rob Theriault wrote:

> Hi:

> "In the instance when the Flight Paramedic determines that sedation is required
> to facilitate intubation, the Flight Paramedic will attempt contact with the
> Base Hospital Physician. If the Patch is impossible or cannot be obtained
> quickly, the Flight Patramedic may administer Midazolam 1-2 mg IV and/or
> Fentanyl prior to intubation and re-attempt the patch."
> 
> When intubation is indicated for the patient with a suspected or confirmed brain
> injury, a bolus of Lidocaine 1-1.5 mg/kg may be administered prior to intuation
> to blunt the effect of raised intracranial pressure."

Correction, should read:

"In the instance when the Flight Paramedic determines that sedation is required
to facilitate intubation, the Flight Paramedic will attempt contact with the
Base Hospital Physician. If the Patch is impossible or cannot be obtained
quickly, the Flight Patramedic may administer Midazolam 1-2 mg IV and/or
Fentanyl 25-50 mcg prior to intubation and re-attempt the patch."
 
When intubation is indicated for the patient with a suspected or confirmed brain
injury, a bolus of Lidocaine 1-1.5 mg/kg may be administered prior to intuation
to blunt the effect of raised intracranial pressure."

Thanks

Rob Theriault  EMCA, RCT (Adv., EMA III,
               Critical Care Flight Paramedic
Bandage 1, Dedicated Air Ambulance
Toronto, Ontario, Canada
E-Mail: rob.t@sympatico.ca
---------------------------------------------
Director of Education and Research
Ontario Paramedic Association

Lamont Cranston wrote:
> 
> do you use nasotracheal intubations in your system? in the system I am
> familiar with they have very high success rate with them, even in closed
> head and facial trauma. I know everyone has seen or heard of the
> intubated cranium, but do you know that it is the only case of this
> happening ever?


We do a fair number of blind nasal intubations. It is a relatively easy form of 
intubation (in my experience) and is a good choice for certain patients, 
including the head injured. I have only had one instance (knock on wood) where I 
could not nasally intubate someone and went the oral route.

Some of the advantages are in the head injured pt:
*no need to manipulated the neck (as one would with laryngoscopy...even with the 
head in neutral alignment)
*not affected by trismus
*if the pt is sitting on the slippery slope of the GCS and has an intact gag 
reflex, the nasal ETT is better tolerated because it sits against the posterior 
wall of the hypopharynx and tends not to stimulate the gag as much as an oral ETT
*in the patient who initially presents comatosed and improves neurologically 
after hyperventilation, it is better tolerated for the reason just metioned. In 
addition, the patient can't bite down on or chew on the tube. Less sedation may 
be required (personal judgement call)
*can be performed on most head injuries, with the exception of the severe facial 
smash. There are no ABSOLUTE contraindications. It's not like passing an NG tube. 
With the nasal ETT you are constantly listening for air movement through the 
tube. Obviouly, oral intubation would be the route of choice in a facial smash.

* also works well in the awake intubation (with some sedation):  

eg. the patient in imminent or actual respiratory failure (my choice, if it were 
available to me however would be RSI)

Cheers

Rob Theriault  EMCA, RCT (Adv.), EMA III
               Critical Care Flight Paramedic
Bandage 1
Toronto, Ontario
Canada

On 27 Aug 1996, Lamont Cranston wrote:

> do you use nasotracheal intubations in your system? in the system I am 
> familiar with they have very high success rate with them, even in closed 
> head and facial trauma. I know everyone has seen or heard of the 
> intubated cranium, but do you know that it is the only case of this 
> happening ever?
> 
> 
> 
> 
Haven't seen an ETT go into the cranium, but I did see a NG tube coil 
up.  When I turned on the suction all I saw was a white flash, followed 
by lots of bright red blood.  Placement of NG tube verified by x-ray.

mike