Rowley wrote:
> Where is the prehospital capnograph? How many of us
> have one to hand? Certainly I do not
You could use one of the disposable colour change capnographs. They are
widely available and have been used prehospital in the US (sorry do not have
the reference to hand). Having said that we do not have one in our packs -
but that may change after this discussion!
Simon
Simon Carley
SpR in Emergency Medicine
Manchester Royal Infirmary
England
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Evidence based Emergency Medicine
http://www.bestbets.org
----- Original Message -----
From: Rowley Cottingham <[log in to unmask]>
To: <[log in to unmask]>
Sent: Thursday, October 04, 2001 6:12 AM
Subject: Re: EtOH and ETCO2
> > 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
>
> [log in to unmask]
> http://www.emergencyunit.com
>
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