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Thu Apr 6 17:43:52 BST 2006

Actually, the literature reflects multiple attempts at intubation can of course cause an increase in ICP and be deleterious.  However, in the Journal of Trauma, there is an article from a couple of years ago about "Scoop and Run" referencing prehospital airway control.  They concluded that BVM with 100% O2 after 2 unsuccessful attempts at intubation and then immediate hospital transfer was the most appropriate response.  And not that we dont already know this, but hypoxemia will increase ICP.  Trauma Candie
> 
> From: Ben Reynolds <aneurysm_42 at yahoo.com>
> Date: 2006/04/06 Thu AM 11:43:56 EDT
> To: "Trauma &amp, Critical Care mailing list" <trauma-list at trauma.org>, 
> 	Melissa Markey <mmarkey at hallrender.com>
> Subject: Re: Re: Rescue Airway Techniques
> 
> There is an evolving body of literature which argues
> exactly the OPPOSITE, that in fact prehospital
> intubation as an independent event in severe head
> injury*, hypovolemic shock** AND in pediatric
> patients*** is associated with HIGHER morbidity and
> mortality.
> 
> 
> Ben Reynolds, PA-C
> Pittsburgh, PA
> 
> *Bochicchio GV, Ilahi O, Joshi M, Bochicchio K, Scalea
> TM. Endotracheal intubation in the field does not
> improve outcome in trauma patients who present without
> an acutely lethal traumatic brain injury. J Trauma.
> 2003 Feb;54(2):307-11.
> 
> *Davis DP, Peay J, Sise MJ, Vilke GM, Kennedy F,
> Eastman AB, Velky T, Hoyt DB. The impact of
> prehospital endotracheal intubation on outcome in
> moderate to severe traumatic brain injury. J Trauma.
> 2005 May;58(5):933-9.
> 
> *Sen A, Nichani R. Best evidence topic report.
> Prehospital endotracheal intubation in adult major
> trauma patients with head injury. Emerg Med J. 2005
> Dec;22(12):887-9.
> 
> *Wang HE, Peitzman AB, Cassidy LD, Adelson PD, Yealy
> DM. Out-of-hospital endotracheal intubation and
> outcome after traumatic brain injury. Ann Emerg Med.
> 2004 Nov;44(5):439-50.
> 
> *Davis DP, Stern J, Sise MJ, Hoyt DB. A follow-up
> analysis of factors associated with head-injury
> mortality after paramedic rapid sequence intubation. J
> Trauma. 2005 Aug;59(2):486-90.
> 
> **Shafi S, Gentilello L. Pre-hospital endotracheal
> intubation and positive pressure ventilation is
> associated with hypotension and decreased survival in
> hypovolemic trauma patients: an analysis of the
> National Trauma Data Bank. J Trauma. 2005
> Nov;59(5):1140-5; discussion 1145-7.
> 
> ***DiRusso SM, Sullivan T, Risucci D, Nealon P, Slim
> M. Intubation of pediatric trauma patients in the
> field: predictor of negative outcome despite risk
> stratification. J Trauma. 2005 Jul;59(1):84-90;
> discussion 90-1.
> 
> 
> --- stefmazur at ausdoctors.net wrote:
> 
> > Melissa,
> > 
> > What is the evidence that shows having an ET tube
> > placed pre-hospital saves these patients
> > "significant mortality and morbidity"?
> > 
> > My reading (admittedly limited) seems to suggest the
> > opposite, so would be interested in what evidence
> > has lead you to your conclusion.
> > 
> > Cheers,
> > Stefan Mazur
> > Emergency Physician
> > 
> > >With all due respect, I have a different suggestion
> > - how about
> > >anesthetists and anesthesiologists willingly
> > sharing their knowledge and
> > >giving paramedics more chances to practice
> > intubation in a controlled
> > >setting (i.e., consider us as important to train as
> > you do residents,
> > >and stop giving the residents all the tubes).  Last
> > time I was in the OR
> > >for ET practice, I got 0 chances out of an 8 hour
> > day.  Why?  Because
> > >anesthesia always found a reason to say no -  No,
> > this patient has caps
> > >on her teeth.  No, this patient is in for elective
> > surgery.  No, we want
> > >the resident to get some experience.  Not a very
> > effective investment of
> > >my time.  And not a very appropriate way to behave,
> > to my thinking.
> > >
> > >Experienced paramedics can intubate quite
> > successfully - and quickly.
> > >The determining factor is not whether you have an
> > MD or other degree -
> > >it is the experience.   Experience in controlled
> > settings helps you
> > >anticipate the problems in the uncontrolled
> > environment - and helps you
> > >understand when you will be able to get the tube,
> > and when you just
> > >secure whatever airway you can get and run.
> > >
> > >Patients may or may not have already aspirated -
> > often they haven't,
> > >and the reason they aspirate is because someone is
> > thumping and pumping
> > >on them.  Having an ET in place saves these
> > patients significant
> > >morbidity and mortality - and isn't that what this
> > EMS is all about???
> > >No, paramedics shouldn't spend 10 minutes on the
> > scene trying to get an
> > >ET tube in.  That is not the same thing as saying
> > that ET in the field
> > >is inappropriate.  If you can get a tube quickly,
> > without undue
> > >deprivation of oxygen, do it.  If you can't,
> > acknowledge you are human,
> > >use an alternative, and get the patient to
> > definitive care.
> > >
> > >The debate about ET in the field is really a
> > question of ensuring
> > >appropriate training and experience.  There are
> > lots of medics out there
> > >who would be very happy to have more experience in
> > controlled settings.
> > >Any anesthetists/anesthesiologists willing to
> > help???
> > >
> > >P.S.  If you prohibit pre-hospital intubation
> > absent hundreds of
> > >intubations (in what time period?), don't forget
> > that residents in the
> > >EMS fellowships  and flight nurses, etc. won't be
> > able to tube either,
> > >until they get that many tubes.  In that case,
> > paramedics should have
> > >the chance to accomplish the same criteria, and we
> > are back where I
> > >started - it all comes down to providing
> > opportunities for experience.
> > >
> > >My .02 worth
> > >Melissa
> > >
> > >>>> SeppelI at wahs.nsw.gov.au 4/5/2006 8:52:48 PM >>>
> > >What say the anaesthetists? Speaking as both an
> > anaesthetist and an
> > >intensivist, I have no problem with what you are
> > saying in principle,
> > >but we are discussing totally different things.
> > >
> > >I use nasotracheal tubes in appropriate patients
> > (the risk of
> > >sinusitis
> > >is often grossly overstated). I have done digital
> > intubation as well,
> > >but that is not something to recommend to an
> > inexperienced operator
> > >and
> > >not a situation I want to be in again. Your key
> > word is "- with
> > >experience". With the right experience you can do
> > anything you like,
> > >but
> > >for the majority of people out there with less
> > experience what you
> > >propose is pretty impractical, whereas there is a
> > lot of data out
> > >there
> > >that the LMA is readily inserted to provide a
> > relaible airway by even
> > >the most inexperienced people with a minimum
> > training. And it's pretty
> > >good for experienced people too, while your heart
> > rate comes down, the
> > >patient's heart rate comes back up, and you think
> > of your next option.
> > >
> > >Nobody has ever called an LMA a "definitive airway"
> > per the ATLS
> > >definition of "piece of cuffed plastic in the
> > trachea". What we are
> > >talking about is 'rescue technique of choice for
> > failed intubation'.
> > >And
> > >in that context aspiration is irrelevant - I'll
> > deal with the
> > >aspiration
> > >later in the ICU, and most of these patients have
> > aspirated anyway,
> > >prior to attempts to intubate.
> > >
> > >A whole different question, which Ken Harrison
> > raised, is whether 'non
> > >experts' (and by that I mean the experience of
> > HUNDREDS of in hospital
> > >intubations first including a fair number of
> > difficult ones) should
> > >even
> > >be attempting to intubate pre hospital, as opposed
> > to simple airway
> > >manouvres and driving fast. The data just isn't
> > there at present to
> > >support prehospital intubation, and things like the
> > Los Angeles study
> > >show that by trying to intubate you waste a lot of
> > time without doing
> > >anything to improve outcomes.
> > >
> > >Food for thought, isn't it?
> > >
> > >Cheers, 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
> > >
> > >
> > >>>> bensonblues at comcast.net 6/04/2006 3:38am >>>
> > >As a wayward Yankee ER doc, I've been enlightened
> > by the LMA
> > >discussion. Haven't used one, but I know they're
> > used in the OR for
> > >short cases, dificult intubations, etc. But, they
> > can't be considered
> > >definitive (do not secure the airway against
> > aspiration). In my
> > >training
> > >at Detroit Receiving Hospital (ca 1980's) almost
> > all of the trauma
> > >patients requiring intubation in the ED received
> > nasotracheal tubes
> > >(NTI). Archaic, eh? But, we were good at it, and
> > rarely was NTI
> > >unsuccessful in the spontaneously breathing patient
> > (ketamine being an
> > >excellent agent to facilitate the procedure, and
> > use a 6.5 - 7.5
> > >cuffed
> > >tube). Even in the apneic pt, NTI can be quite
> > successful and fairly
> > >easy to perform - with experience. I still use NTI
> > in dificult
> > >airways,
> > >and "rescued" one apneic fellow with no neck just
> > the other day (the
> > >intensivists groan, because of risk of sinusitis).
> > Another technique
> > >is
> > >digital - by placing your 2nd and 3rd fingers in
> > the hypopharynx volar
> > >side up, I have also been able to guide the tube
> > into 
> === message truncated ===
> 
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