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Thu, 4 Apr 2002 12:29:22 +0100

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Jim,

It is critical to establish a patent airway and to deliver high flow oxyg=
en to your patient as rapidly as possible. My approach to this on arrival=
 on scene, irrespective of whether you have the resources for RSI/paralyt=
ic agents, would be to insert 2 nasopharyngeal airways (size 6.0 or 7.0) =
if possible, an appropriate sized oral airway (not possible in your patie=
nts because of trismus) and assisted ventilation with a BVM with reservoi=
r and appropriately sized face mask. Even in the presence of vomitus, it =
is usually possible to achieve some ventilation in this all too common si=
tuation. Despite the views of the ACS, I do not consider a base of skull =
fracture in this setting a contraindication to the use of nasal airway ad=
juncts - it is essential that those inserting these adjuncts are adequate=
ly trained in their use.

Finally, if despite the above use of airway adjuncts, you cannot ventilat=
e your patient with a BVM, cricothyroidotomy may need be considered as th=
is may be the only route in which a definitive airway can be rapidly esta=
blished before the patient becomes obtunded and looses their upper airway=
 reflexes. Once the latter has occurred, although endotracheal intubation=
 may be successful, the opportunity for survival may be lost.

John Black
Emergency Department
John Radcliffe Hospital
Oxford UK =20

Message: 15
From: "James A. Johnson" <J.Johnson@Valley-hosp.com>
To: "'trauma-list@trauma.org'" <trauma-list@trauma.org>
Subject: paralytics vs. surgical cricothorotomy in the field
Date: Tue, 2 Apr 2002 15:25:19 -0900
Reply-To: trauma-list@trauma.org

I had a trauma pt with a closed head injury secondary to snowmachine
accident. pt was unconscious/unresponsive, no other trauma noted pt resp.
rate 32-34 irreg. pt jaw clamped. unable to call life flight due to weath=
er.
ground transport time code red 20-25 min. to a non trauma E.D. 5 mins. in=
to
transport pt began to show signs of posturing and started vomiting, pt ha=
d
to be rolled and suctioned but was unable to clear airway effectively. Pt
then started to brady down to the 30 despite bvm assist. in our service a=
s
an  EMTIII we are able to provide many advanced skills and we have
progressive standing orders, however it's been a fight to get the sponsor=
ing
physician to allow paralytics in the field. stating he feels it may be
misused in the out lying areas who have lower run volumes and weaker skil=
ls.
My thoughts are if they lack the skills don't let them use it, other
thoughts from the paramedics I have spoken to feel a cric is preferred. I
would rather use a short acting drug to allow me to tube than cut someone=
's
throat, because I feel if the attempt is missed I can go back to the BVM,
and oral airway. comments please.

Jim Johnson EMT III

  Get more from the Web.  FREE MSN Explorer download : http://explorer.ms=
n.com

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<HTML><BODY STYLE=3D"font:10pt verdana; border:none;"><DIV>&nbsp;</DIV> <=
DIV>&nbsp;</DIV> <DIV>Jim,</DIV> <DIV>&nbsp;</DIV> <DIV>It is critical to=
 establish a patent airway and to deliver high flow oxygen to your patien=
t as rapidly as possible. My approach&nbsp;to this on arrival on scene, i=
rrespective of whether you have the resources for RSI/paralytic agents, w=
ould be to insert 2 nasopharyngeal airways (size 6.0 or 7.0)&nbsp;if poss=
ible, an appropriate sized&nbsp;oral airway (not possible in your patient=
s because of trismus) and assisted ventilation with a BVM with reservoir =
and appropriately sized face mask. Even in the presence of vomitus, it is=
 usually possible to achieve some ventilation in this all too common situ=
ation. Despite the views of the ACS, I do not consider&nbsp;a base of sku=
ll fracture in this setting a contraindication to the use of nasal airway=
 adjuncts - it is essential that those inserting these adjuncts are adequ=
ately trained in their use.</DIV> <DIV>&nbsp;</DIV> <DIV>Finally, if desp=
ite the above use of airway adjuncts, you cannot ventilate your patient w=
ith a BVM, cricothyroidotomy&nbsp;may need&nbsp;be considered as this may=
 be the only route in which a definitive airway&nbsp;can be rapidly estab=
lished before the patient becomes obtunded and looses their upper airway =
reflexes. Once the latter has occurred, although endotracheal intubation =
may be successful, the opportunity for survival may be lost.</DIV> <DIV>&=
nbsp;</DIV> <DIV>John Black</DIV> <DIV>Emergency Department</DIV> <DIV>Jo=
hn Radcliffe Hospital</DIV> <DIV>Oxford UK&nbsp;</DIV> <DIV>&nbsp;</DIV> =
<DIV>Message: 15<BR>From: "James A. Johnson" &lt;J.Johnson@Valley-hosp.co=
m&gt;<BR>To: "'trauma-list@trauma.org'" &lt;trauma-list@trauma.org&gt;<BR=
>Subject: paralytics vs. surgical cricothorotomy in the field<BR>Date: Tu=
e, 2 Apr 2002 15:25:19 -0900<BR>Reply-To: trauma-list@trauma.org<BR><BR>I=
 had a trauma pt with a closed head injury secondary to snowmachine<BR>ac=
cident. pt was unconscious/unresponsive, no other trauma noted pt resp.<B=
R>rate 32-34 irreg. pt jaw clamped. unable to call life flight due to wea=
ther.<BR>ground transport time code red 20-25 min. to a non trauma E.D. 5=
 mins. into<BR>transport pt began to show signs of posturing and started =
vomiting, pt had<BR>to be rolled and suctioned but was unable to clear ai=
rway effectively. Pt<BR>then started to brady down to the 30 despite bvm =
assist. in our service as<BR>an&nbsp; EMTIII we are able to provide many =
advanced skills and we have<BR>progressive standing orders, however it's =
been a fight to get the sponsoring<BR>physician to allow paralytics in th=
e field. stating he feels it may be<BR>misused in the out lying areas who=
 have lower run volumes and weaker skills.<BR>My thoughts are if they lac=
k the skills don't let them use it, other<BR>thoughts from the paramedics=
 I have spoken to feel a cric is preferred. I<BR>would rather use a short=
 acting drug to allow me to tube than cut someone's<BR>throat, because I =
feel if the attempt is missed I can go back to the BVM,<BR>and oral airwa=
y. comments please.<BR><BR>Jim Johnson EMT III<BR></DIV> <DIV>&nbsp;&nbsp=
;</DIV> <DIV><BR><BR>&nbsp;</DIV></BODY></HTML><br clear=3Dall><hr>Get mo=
re from the Web.  FREE MSN Explorer download : <a href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2002/3D'http://explorer=
.msn.com'>http://explorer.msn.com</a><br></p>

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