Advanced Airway for QL 5 Med Techs

[transvap0r]

I know that most people agree that no medic, no matter what level of training you have, should be doing rapid sequence intubation (aka paralytics with induction), period. Nor will any doctor ever allow you! If you compare EMS accross Canada, there are very few EMS systems which allow RSI as part of a pre-hospital protocol (not including flight paramedics/ air ambulance, which are a seperate entity of their own), Alberta being one of the only provinces where paramedics can RSI. So if civillian paramedics cannot RSI, then obviously military medics cannot/should not when you compare the frequency of use of these advanced airway skills. I don't know how RSI came into conversation here, but I think most disagree with this idea anyway, so I won't talk anymore about it! Don't forget the reasoning behind performing RSI in the first place, and for acute traumatic airway management in the prehospital setting, "awake" intubation is probably ok. Adding Succinylcholine and versed/fentanyl/propofol mix will only complicate hemodynamics even further in the field.

I'm very confused however, maybe someone can clarify.. it was mentioned several times that cric's should be part of a QL5 scope, and that they are used as the initial advanced airway next to NPA's.... all I can say is wow, that's a pretty large gap in airway management. Has anyone ever heard of the acronym "BARS"? If you have, you will understand my frustration. I can't see how you can justify performing a cric on a pt in order to maintain an advanced airway, especially when there are blind-insertion endotracheal intubation methods which work very well, such as the lighted-stylet (Light Wand). Cric's are extremely invasive, and there are other options that are easily taught and used widespread, and are very fast to use. Just a thought!

 

[Armymedic]

The use of crics in military medicine is proven. When there is trauma to the upper airway, the only way to secure the airway is to stick a cut off 6.0mm tube into someones trachea.

 

[transvap0r]

Okay that does make sense, and cric's are definitly indicated in the situation of severe facial/ upper airway trauma where laryngoscopy and/ or endotracheal intubation is impossible.... this is an indication for a cric in all ALS EMS sustems who have cric's part of their scope of practice. My question is... if the patient has severe multiple system trauma to extremities, chest, back, etc, but no upper airway issues, and now needs an advanced airway in place in order to maintain a patent airway, a cric would be a very invasive unnecessary when ETT can/ should be performed. Do we still give the patient a cric in the field?

 

[Armymedic]

Circumstance dependant, yes. 2 primary issues without getting into the skills....

1. light - need to have a white light to see into the cords. Negated somewhat with technique that does not open the Lscope until it is inside the mouth, still ET skill > cric skill.

2. light - All the equipment needed for intubation is a bit heavy, and needs batteries. Cric just needs a half tube, a knife, a 14 ga catheter and a couple safety pins.

 

[kj_gully]

Another factor being overlooked/ taken for granted is positioning. you need very specific body position to accurately intubate, even with the new fibreoptic scope. I know you can't cric a patient just any old way, but with some of the prefab devices out there, it isn't as restrictive. Even surgically, you only need one body length area, vs 2 for ET

 

[david_wright]

Hello all.

I've been reading this topic, with some interest, as I am a serving doctor in the Australian Army Reserve as well as being an anaesthetic trainee in civilian practice.
I can add a bit to your debate, and I appreciate and respect the range of opinions on here, although I do not believe all are correct.
Firstly, I personally believe that advanced airway procedures should be taught to advanced medics. I don't believe the medics should be allowed to undertake these procedures autonomously unless they are unable to contact a more senior person. That is, if there is time, the medic should call a doctor, senior medic etc and outline the patient situation and then seek instruction. If there is no capability to speak to a more senior colleague, then it is a matter for personal judgement. I am not saying that medics lack the ability to appraise a situation and undertake a plan of action, but I have seen considerable damage done to patients by even experienced civilian operators. If an airway undergoes attempted intubation, and it turns out to be a "can't intubate" scenario, then the consequences are dire. That said, unless someone with a wealth of experience was immediately on hand, the casualty may die, and may even do so with expert help.

The use of neuromuscular blocking agents is a contentious issue. Suxamethonium remains the gold choice for rapid sequence intubation although there are questions about raised intracranial pressure, etc. If a longer acting agent is administered to a patient, then you may have a considerable lag time before intubating conditions are ideal. There is also the danger of encountering the "can't intubate, can't ventilate" scenario. This is a genuine brown underpants moment. I would recommend others to avoid the use of NMB in the field unless trained in their use in a variety of environments. I cannot advocate the use of airway blocks for emergency airway provision. The idea is risky as there are a lot of vascular structures in the neck, there is a risk of intravascular injection, there is also the risk of pneumothorax, nerve damage and failed block. Most nerve blocks take time to "mature", sometimes up to 20 or 30 minutes. There is simply not enough time in an emergency to do a nerve block unless the person doing the block has done heaps of them and is comfortable doing them. There is also the risk of infection from jabbing a needle in the neck in less than clean surrounds. Personally, having not done many airway blocks (partly due to the use of NMB etc) I would not want to do them if I could avoid it. An alternative is to spray the vocal cords with local anaesthetic, such as 4% lignocaine or even 2%. This can often prevent laryngospasm. Interestingly, intubation intself does not necessarily require a specific body position. The "sniffing the air" position merely maximises the chance of successful intubation. Patients with neck injuries can be intubated with manual inline stabilisation. Patients can be intubated sitting up, with the laryngoscopy held i the right hand like and icepick. They can be intubated lying on the ground with the person intubating lying next to them. Fibreoptic bronchoscopic intubation can be performed in front of, or behind the patient. Patient can be intubated orally or nasally. In short, a skilled operator should be able to intubate in a variety of postures and positions.

Cricothyroidotomy is a rescue technique and may be used to buy time. Jet insufflation is even less able to maintain oxygenation over a long period, but both of these are useful in an emergency. I would advocate the use of needle cricothyroidotomy in an emergency if other techniques failed. There are obviously large and important blood vessels in the neck, so adequate training is essential.

My advice would be to teach intubation and emergency airway techniques to advanced medics. I would teach direct laryngoscopy. I would also make sure that there was one single alternative to direct laryngoscopy (Airtraq, Pentax AWS, GlideScope whatever) and only one and that operators were familiar with it's use. I would include training in the use of LMAs and Proseals and have these as the first step after failed intubation. I would recommend that all who intubate patients are familiar with failed airway scenarios and procedures.

In summary, people die from a failure to ventilate, not intubate. Advanced techniques should be taught but everyone has their own opinion on who should be taugh what and by who. In Australia, paramedics undergo hsopital reaccreditation for intubation but they do not use neuromuscular blockers. They are also trialling the use of intubating LMAs in the field.