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Fri Oct 5 12:22:48 BST 2007

To elaborate, the patient was someone I would not have transferred in  a
million years. In fact, the case was used later as an example of how not to
do things.
Patient was 24, weighed 24kg, had osteogenesis imperfecta, was incredibly
deformed. Doctor doing transfer had done several years of anaesthetics,
however, and the decision maker was a consultant.
Everyone should have known about tube positioning and fixation.

Nick Macartney 

-----Original Message-----
From: Ian Seppelt [mailto:SeppelI at wahs.nsw.gov.au] 
Sent: 04 October 2007 23:53
To: atacc.doc at btinternet.com; nick at macartney.org; 'Trauma &amp; Critical
Care mailing list'
Subject: RE: Cut vs uncut tubes

I suggest that Nick's case reveals inadequacies in the interhospital
transport process. Who was the attendant? Anaesthetic or ICU registrar who
should have known better? Junior doctor with no idea? Skilled paramedic with
intubation skills (who again should have known better)?
Or non-paramedic, who again would not be expected to have any idea.

In the context of a prehospital paramedic system and a good interhospital
retrieval system [which is the envionment I work in], I maintain there is no
place for cut tubes and a lot of potential problems with tubes that are too
short.

The only purpose for a cut tube is to prevent (inadequately trained) people
pushing it in to far [and that applies equally to doctors, nurses and
ambos].

Cheers, Ian

>>> nick at macartney.org 5/10/2007 3:06am >>>
While I agree to some extent with Ian, having been on the receiving end of a
patient transferred from an icu with a tube in the right lower lobe bronchus
- yes, not the right main bronchus, beware the law of unexpected
consequences.
A change made for an apparently good reason, might cause another problem....
There is not the correct length of tube, and IMHO no formula will get it
right at all times. Training is the key, but even then...
After all, my patient was transferred from one hospital to another.
Nick Macartney 

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]
On Behalf Of Ian Seppelt
Sent: 02 October 2007 06:24
To: atacc.doc at btinternet.com; Trauma &amp; Critical Care mailing list
Subject: Cut vs uncut tubes

I'll disagree with Mark's last sentence. Pprovided the personnel are
appropriately trained there is NO problem with uncut tubes! Having been on
the receiving end of cut tubes in rapidly swelling burnt patients I can tell
you it is no fun at all having to change these tubes. The NSW Ambulance
Service has only carried cut tubes from the beginning of the paramedic
service in 1976, but is about to (thankfully) abandon that and only use
uncut tubes. The risks of inserting a tube that is too short, and
subsequently needs to be changed [and we see this at least once a month], is
much greater than the risk of an endobronchial tube, in the hands of a
trained operator.

Cheers, Ian

Ian Seppelt FANZCA FJFICM
Senior Staff Specialist
Dept of Intensive Care Medicine
The Nepean Hospital, PO Box 63 Penrith NSW 2751 Director of Clinical
Research, Sydney West AHS Clinical Lecturer, University of Sydney

>>> atacc.doc at btinternet.com 21/09/2007 2:53am >>>
HI Tug,
Although a longer tube and your catheter mount will increase the dead space,
in adults this volume will have little effect as compared to the overall
tidal volume of 6-7ml/|Kg. 
Children are a very different affair and ideally with small children and
babies (<25Kg and below to pick a number!) your breathing system should
connect directly to the tube, as even 10-15mls could be significant.

Uncut ET tubes are always a controversial area. In major facial trauma,
burns or other conditions producing major swelling then they are
appropriate, but in most other circumstances they can produce problems with
endobronchial postioning, migration and kinking.

Mark F
UK

----- Original Message ----
From: "tuganddawn at talktalk.net" <tuganddawn at talktalk.net>
To: trauma-list at trauma.org
Sent: Thursday, 20 September, 2007 12:45:54 PM
Subject: Dead space

Hello everyone,

   I recently had a conversation with a Paramedic colleage who
suggested that if you intubate a patient (prehospital) with an uncut
ETT
you should not use a cobb connector (the corrugated plastic tubing
betweeen BVM and tube) because of the excessive dead space created.
Though I appreciate that we are using manual ventillation I disagreed
with this in adult patients due to the relatively small size of these
connectors.
   I appreciate that this is an extremely basic question but I am
curious to see what the consensus is.
   Thanks for your time and patience ladies and gents and look forward
to your responses.

  Take care and Kindest Regards

FF Tug Crumpton SR para
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Cut vs uncut tubes