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Rowley, You must just be better at laryngoscopy than me! Simon ;-) Simon Carley SpR in Emergency Medicine Manchester Royal Infirmary England [log in to unmask] 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 >