The who, when, why and
whatnot
“A man’s got to know his limitations”
Dirty Harry
The patient CANNOT MAINTAIN their own
AIRWAY
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Intoxicants
Head injury
Neurological event
Altered level of consciousness
There is an increased potential for ASPIRATION
• Altered level of consciousness
• Problem with the airway/bleeding/vomiting
The patient cannot effectively VENTILATE
• Asthma
• COPD
• Neurological cause
• JPFROG
The patient CANNOT OXYGENATE themselves
• Pulmonary edema
• Pneumonia
• ARDS
• Toxic- cyanide, CO
Things that will get WORSE and cause TROUBLE
• Inhalation injury that swells
• Caustic ingestion
• Anaphylactic airway
• Uncontrolled airway bleeding (surgical?)
• Septic patients
• ICH
• High degree C spine fx
• Uncooperative trauma patients with injuries
The enemy of good, is better
If the patient can ventilate and oxygenate, can you
justify it? Medically and in court?
Can this be better managed in a while vs. now in
the wild west? Will the outcome be favorable?
If you don’t do it now, can you do it later? Are
you prepared to do whatever it takes?
“Hopefully the only in flight
intubations, are those that
could not have been
anticipated. It IS our job to
see 30 minutes into the
future and act accordingly”
Trishism
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LOOK- teeth, jaw, tongue
EVALUATE- 3-3-2,
Malampati, next slide
Obstruction- Stridor, dysphagia, hoarseness
Neck mobility- arthritis, c spine, kyphosis
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Paralytics do not sedate!!! THOU SHALT
NEVER, NEVER PARALYZE AND NOT
SEDATE
Hypnotic- ETOMIDATE 0.3 MG/KG
Benzodiazepine- VERSED 0.03 MG/KG
Sedative etc.- Ketamine 1 to 2 MG/KG
Consider respiratory status, blood pressure, co
morbidities and injuries
PARALYTIC DRUGS chosen for their speed of
onset and duration of action. They interfere
with neuromuscular conduction with resulting
paralysis, needed to facilitate an ETT
Rocuronium- not with head injuries and not with
suspected difficult AW, WHY?
Succinylcholine- not with hyperkalemia, dialysis,
late crush or burn injuries, open globe eye
injuries, bedridden patients, MH.
Vecuronium- Think VERY long acting
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Observe for signs of pain, ETTs HURT
Treat pain with fentanyl 1 to 2 MCG/KG
Repeat sedation with Versed
This is actually first, you should have asked about
MALIGNANT HYPERTHERMIA
Hereditary
Triggered by anesthesia
Increased muscle contraction, sudden prolonged
calcium release, increased lactic acid, high
body temp
Treated with Dantrolene-works outside the CNS,
reduces calcium release, acts on rapidly
contracting motor units, blocks sarcoplasmic
blah, blah, blah
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http://emedicine.medscape.com/article/80222
-overview#a30
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Island Air Ambulance Guidelines, Dr. Sullivan
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ME