> Rowley said
> > You should not be intubating in any position where you cannot
> > accurately
> decide on
> > correct intubation. There is no substitute for seeing the tube pass
> through the cords, and I
> > do not agree with the 'position statement'. (regarding ETCo2
> > confirmation
> of ET placement I presume).
>
> I'm surprised at his in a way, I thought you would be an advocate. I
> agree
> that seeing the tube through the cords is a pretty powerful way of
> knowing
> it is there (though senior anaesthetists have told me that it is still
> possible to be mistaken). However, many of my RSIs are in trauma
> patients in
> the neutral C-spine postion.About a third of these are grade 3 views so
> seeing th tube go through the cords is not possible. What then? I must
> admit
> that I am very happy to see the capnograph respond in these situations.

Robbie:

No way should you be in that environment! ;-) Fair question - how do you behave if a
patient is inverted in the prehospital environment? First, use Occam's razor. Will the
problem I wish to solve be solved by this manoeuvre? An upside-down patient doesn't
have an airway problem without concomitant facial damage, nor does he have a risk of
aspiration while upside down. Only use a difficult intervention when a simple one is
inadequate or risks worsening the situation. I would consider BVM first in this situation;
yes holding the mask on is difficult, but it is less cavalier than blindly prodding down a
throat. And, actually, you (possibly unwittingly) have provided the most powerful
argument in favour of my stance. Where is the prehospital capnograph? How many of us
have one to hand? Certainly I do not. However, I do have clinical experience, eyes and a
stethoscope. I have intubated the oesophagus in a patient awaiting elective surgery.
However, she deteriorated unexpectedly, and I went through recovery drill - when in doubt
pull it out - and recovered the situation uneventfully.

Simon:

I once asked a neurosurgical anaesthetist at Queens's Square who intubated vast numbers
of patients with known unstable cervical spine fractures how he intubated them, and he
looked me square in the face and said quietly, "Exactly the same way you do. I just make
sure my defence subs are up to date." You have competing requirements in these patients,
and with respect, I believe that you are straying to the wrong side of the line. Consider
your competing fears: the mortality of failed oesophageal intubation, and the risk of high
tetraplegia. For you to render a patient, with a neck fracture who has no neurological
disability before you start, tetraplegic you have to move the neck in an uncontrolled
fashion an amazing amount, even assuming that the fracture was likely to lead to damage
in the first place.  Harry Baker wrote one of the finest monographs on management of the
unstable neck, and he pointed out that in fact extension of the neck was the least
dangerous manoeuvre.  So I would advocate that you are putting your patients at
increased and arguably unacceptable risk by not gently extending the neck and intubating
safely. Remain alert to the possibility of oesophageal intubation; while a capnograph is of
assistance, it may pack up, be elsewhere or unavailable for any of a dozen reasons.

Best wishes,


Rowley Cottingham

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