List Archives

Wed Dec 8 01:59:31 GMT 2004

Well said, Ken!

While I agree with you, where did your figure of 50 tubes/yr come from?

I suspect most emergency physicians and intensivists do not come anywhere near that, if only because most of the intubations are done by juniors. In my own institution I think I am the only intensivist that does (because I do a neuroanaesthetic list on the side) and even somewhere like Westmead I suspect only one intensivist meets your standard (similarly, because he gases in the private sector).

Where I seriously think we are heading is the simulation centre (where you can do half a dozen seriously hard intubations in a morning, using a variety of techniques to get yourself out of trouble). Even within anaesthesia, most intubations are simple. There are three paradoxes: (1) the most senior, experienced people do mainly the easy daytime work, (2) most emphasis is on recognising anatomic difficulty ("predicting the difficult airway") rather than physiological difficulty ("recognising the sick patient with no reserves who might die on the end of your syringe"), and (3) those least trained and equipped do the hardest and most risky intubations (the sick patients in the deepest darkest medical wards at 3am).

I think we still have a long way to go!

Best wishes, Ian

Ian Seppelt FANZCA FJFICM
Staff Specialist in Intensive Care Medicine
The Nepean Hospital, 
PO Box 63, Penrith NSW 2751
Clinical Lecturer, University of Sydney

>>> kenh at careflight.org 12/07/04 12:59pm >>>

I am an anaesthetist from Sydney who has worked in prehospital medicine for
13 years and now teach others how to do pre hospital medicine.

1/ there is more emotion than fact/science around this issue
2/ NO ONE has shown nay benefit in pre hospital intubation vs good bag
ventilation in any STUDY anywhere
( as an anaesthetist who works extensively in this field , this galls me)
 matter of fact the only two vaguely randomised trials, San Francisco and
San Diego, have shown worse outcomes if anything)
3/ Within the hospital walls it is basically accepted that if you are not
doing 50 ETT's a year you SHOULD NOT BE DOING them and so we only teach
anaesthetists, intensivists and ED physicians to do ETT now.
4/ ETCO2 is the only acceptable method of determining placement of ETT's and
the Nellcor 75 (and the like) will record the REAL observations so that they
can be kept for QA later (if that frightens you, why are you doing the ETT).

BUT lots of pre hospital providers across the world do RSI without any
evidence it does any good ( I do understand it would be really hard to sit
by someone with a GCS of 8 and trismus and not be able to do "anything"
however)

There are a number of different scenarios/factors
1/ distance from Trauma hospital. As numerous people have pointed out, there
is precious little place for RSI in urban trauma and much more place in long
distance trauma.
2/ If the patient is trapped or down a ravine or whatever the TIME to
hospital could be long even if the distance is small
3/ Head injury  If the patient has only a head injury then there is more
place for keeping the CO2 stable ( but you need a ventilator to do that not
just a self inflating bag) and the cerebral venous pressure down by stopping
the obstructed breathing.

So it is rarely indicated in intraurban penetrating trauma and is more
indicated in rural blunt head injuries.

As for drugs

1/ Etomidate is good, it CAN drop your BP but is less likely to than most (
we don't have it in Australia)
2/ Thiopentone is good but you have to get the dose right, if the BP is low
because they are shocked give 50 or 75 mg
Only
3/ Ketamine is good (but don't use it for the first time in a hypotensive
patient!!)
4/ Morphine is crap, it takes 5 minutes to work!!!
5/ Midazolam as a "induction agent" in a hypotensive patient is CRAP and
should NOT be used. The one thing it will do is maybe make the patient
amnesic, so they wont remember what happened but
	a/ It takes 5 minutes to work( look up a pharmacology book if you
don't believe me)
	b/ It will drop your BP and what is more it will drop it AFTER you
get the tube in and so they will crash some more because they don't have the
stimulus from the cold steel in their throat to raise it
	c/ It doesn't depress pharyngeal reflexes that well in small doses,
so it can make the intubation harder.(look at now much midazolam you can
give someone for "sedation" and they still keep their reflexes)

As for training/certification
1/ you should be doing 50 tubes a year = i/week
2/ you should be very good at Bag valve mask ventilation
3/ you should be competent at inserting rescue airways (LMAs or proseals or
combitubes or whatever)
4/ you should be trained in cricothyroidotomy
5/ you should be part of a QA programme where every ETT is assessed.

Enough of a sermon

Ken Harrison

--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/traumalist.html
######################################################################
Attention: 
This message is intended for the addresses named and may contain 
confidential information. If you are not the intended recipient, please
delete it and notify the sender. Views expressed in this message are 
those of the individual sender, and are not necessarily the views of 
Wentworth Area Health Service.

This e-mail has been scanned for viruses
######################################################################

List Archives

For your convenience, find the Trauma List Archive Below

sedation