Question for Medics: Nasal Intubation & "Jumping In"

[firemoose827 324]

I have a question for you Paramedics out there...Its a QUESTION...not a bash. I am not even mentioning any names of organizations. Just a question to clarify something that has been bugging me all weekend.

I was a EMT-CC 8 years ago and let it drop due to family obligations, I am currently just a Basic. At my PT EMS job this past weekend we had a motorcycle vs. car accident...*ouch*...the passenger of the motorcycle got thrown into a field and suffered a head injury. When we arrived she was decorticate posturing, R pupil blown L pupil constricted, breathing, pulse, responsive to pain, incoherent mumbling. I did trauma assesment while my medic partner set up for IV. BP 140/110, P 100, R 28 shallow, no visible bleeding, PT wearing helmet. The helmet was a threat to the airway so we did a helmet removal, immobilized her and was attempting a second IV when a County Coordinator showed up and started to help with our pt. My medic was trying a hard stick so he didnt see, but when I was done with second BP I looked up to see the county medic lubing her nares and starting to nasaly intubate......???????......My question is one: Isnt nasal Intubation contraindicated in a PT with Head injury? Or has that changed? Two: He just jumps in and starts treating our PT without checking with my medic, isnt there something wrong with that?

We ended up flying her out, the bird landed right across the street, as we were walking her over she started to seize. But I heard she is in critical condition in ICU. It just bothered me and needed to ask some of you for input.

Thanks

Moose

[x635 4,066]

It depends where you practice. Nasal intubation is GENERALLY contraindicated in trauma with head injury in most systems, BUT, if the patient can't maintain their own airway, and you can't intubate for some reason orally, then having some sort of airway is better then having no airway at all- because either way may cause brain damage. You just have to be really careful in your placement, and be aware of the anatomy of the face/skull and what may have been misplaced during the injury. Also, you've got to confirm tube placement, as usual, but in the case, as early as possibly, the best way is to feel or see the tube go in the upper airway.

I've practiced in different systems om different states, and it's always been different. However, the issue is hotly debated.

As far as the other medic just jumping in without consulting the other Paramedic, that's just plain wrong. In my eyes, when you first assess a patient, you develop a treatment plan. If another medic shows up, it's common courtesy to ask what that medic needs. To just jump in is a "cowboy" move and can be detrimental to the patient.

[Guest]

Moose- first...you are NOT "just an EMT". EMT's are an integral part of the prehospital machine, and in some instances, worth more than a medic. I was always told that as EMS providers, we are the elite, and "once EMS...Always EMS"

Than being said...I have also worked in many regions in the state, and I have NEVER seen anywhere where a nasal intubation was allowed on a confirmed head trauma. Even where trismus (the clenching of the jaw, usually indicative of TBI, especially a basalar fracture) it is aceptable to administer Valium to relax the mandible, whereas a oral intubation can be attempted. I have even been forced to do a needle crichotheratomy due to the contraindication of nasal intubation on a TBI due to a baseball bat to the occipital.

As for the medic "jumping in"....if the first medic was doing something detrimental to patient care, then the second medic could, in theory, jump in and assume control of patient care. However, an explanation afterward would be the "right thing" to do, as an explanation for his/her actions. If the medic jumped in to assist, that should have been verbalized as soon as he/she stepped in.

Remember....we're all on the same team.

Stay safe...

[Guest alsfirefighter]

Jonesy excellent question and one that is still debated nationwide.

Recently and I would say for about a year or a little longer there has been much discussion about this topic and skill in many seminars and constortiums I've gotten to attend and listening to many trauma doctors and other affiliated MD specialities this is becoming more of an accepted practice. Ive also heard lecturers during presentations speak about how the whole risk of placing an ET tube or NG tube into the cranial space is actually a rarity and overly sensationalized by that one x-ray photo we've all seen with the NG tube coiled up in the head. In fact I think we could superimpose every copy I've seen over the years on top of each other.

But as with anything in our field or the science of medicine, for every one that I can find that makes a statement on one side, you can find 2-3 that want to counteract it.

Would I have more then likely attempted that...no. Nasal intubations are not the easiest of intubation techniques to begin with. Maybe some more of my colleagues can jump in with some additional signs with TBI, but it also has been my experience with head trauma that was later to be confirmed to be a basal skull fracture I would have to say that a very high percentage of my patients presented with hemhorrage from both the nose and ears and then developed battle's sign at some time during transport.

I'm lucky enough to work in a system that pretty much we know everyone and who we are and who is comfortable with assisting when arriving. Even with that...its pretty much a courtesy to say at least "what's up, you need anything else done?" Etc. That is the clue that you can assist if wanted.

[ONEEYEDMIC 68]

I actually loved to nasally intubate somebody. I thought it was quite easy. Of course the PT is conscious when you are doing it maybe that is why I liked it so much. In the scenario above I know that it was contraindicated when a person has a head injury. That could have changed but I doubt it.

[Guest WolfEMT]

Unless something drastic has changed, the indication for airway adjuncts in traumatic patients is oral only, after the patient's mouth has been opened using the jaw-thrust maneuver. This is something that is taught in the State and National EMT-B curriculum and the Medic should have known.

[emtpjimd 1]

In my region, you aren't going to nasally intubate a head trauma. The only reasons for a nasal intubation (clenched jaw, conscious CHF pt, etc) were pretty much removed once we had full RSI given to us. Even with a severe facial issue, you generally have compromise of the airway, and go for a surgical cric. or quick-trach. DOn't get me wrong, there's a place and time for a nasal intubation, but it seems that in my area the pharmacology can help eliminate the need.

About the jumping in, unless it's someone you know and work with on a regular basis in your own system, that's a no-no. As the first medic, you own that scene, and as they say it "rolls downhill". If the other medic makes a poor decision, then you also own part of it. A not so good scenario.

[firemoose827 324]

Im glad a few of you mentioned RSI, because thats what my partner wanted to do with her. She did have clenched teeth but I feel the scissor technique could have opened her mouth...and with the RSI it would have been easier to do that and than easier to control her breathing. Shortly after the nasal intubation I had trouble keeping her Resperations in a safe range with the BVM, she kept fighting it.

But what realy gets me, now that I have heard some of your views, is that when we got to the flight medic he points at the tube and says "Excellent job on the tube man." I guess he forgot the contraindications too.

After transfer of care we went to clean up the "field" that we managed to make a complete mess of and the county medic just goes to his vehicle and takes off....doesnt help us, doesnt collaborate info for the PCR...just leaves. The sad part is this medic was an EXCELLENT medic, I worked with him my whole 20 year career and he taught all of my classes and hes been the Coordinator for as long as I can remember. I hope hes not burnt out, this makes me worried about him.

Thanks for your input.

Moose

[Guest partyrock]

jonesy, your patient screams TBI. Here in my little neck of the woods nasal intubation of this patient is strictly forbidden and would result in a do not pass go do not collect $200 trip to Dr. Gonzales' office for everyone involved in patient care. Anyone from FDNY EMS can attest to our Med Directors intolerance of violating protocols. However the person who would really catch the wrath would be the medic who just jumped in and started operating on someone else's patient. Unless the crew is actively killing the patient you'd be hard pressed to justify jumping in like that.

[WAS967 97]

What people seem to forget (or just plain don't know) is that there are two types of contraindication: Relative and Absolute.

Nasal intubation of a patient with r/o Head Injury is a RELATIVE contraindication. Unlike a contraindication that is absolute like giving ASA to a patient with a known severe allergy to it. As demonstrated by the comments above, it's obvious that people's opinions on the subject vary, and in the end it comes down to following local protocol.

Personally, I love nasal intubation. My very first field tube was a nasal. One of my most recent tubes was a nasal. In fact if I went back and reviewed all the tubes I've done, I'd say close to 20% of em were nasals.

Would I nasal the above mentioned patient? Probably. Would I be careful about it? Hell yeah. But the fact of the matter is, they have a TBI and most likely need aggressive airway control. Both systems I work in do NOT have RSI. My only alternative? Versed. Needless to say, I have not seen very good results with Versed alone in putting down a combative head injury patient. (And one system all we carry is 4mg on hand ).

And as for the jumping in medic, yeah, it's a bit uncool to just drop in and start taking over. Sounds more like a turf issue than anything. Or maybe someone was just overzealous.

Edited September 13, 2007 by WAS967