trauma-list digest, Vol 1 #1817 - 10 msgs
Stephen R.
trauma-list@trauma.org
Fri, 02 May 2003 23:54:09 -0400
I agree that nasal airways are helpful in semi-concious patient (as my EMT
instructor said "they were designed for use on obnoxious drunks"), however
you must look at this from a legal standpoint (My fiance is a law student,
so i get an earful about the legal side of what I do for a living from her).
I certainly wouldn't want to have to explain to a civil court jury why I
more or less transnasally lobotomied the plaintiff's family member, when any
EMT or medical text worth it's salt says that you don't stick things up the
nose of facial and head trauma patients. I'm kind of partial to my personal
belongings and what little money I make and share with Uncle Sam, I don't
want to have to share it with anyone else.
Sincerely,
Stephen L. Richey, CRT, EMT-I/D, ERT, FF
> 5. Re: A trauma mystery (SKIPAPA1@aol.com)
> 6. Re: trauma-list digest, Vol 1 #1816 - 14 msgs (SiR,avd Eigersund
>amb)
> 7. Re: trauma-list digest, Vol 1 #1816 - 14 msgs (SiR,avd Eigersund
>amb)
> 8. Re: trauma-list digest, Vol 1 #1816 - 14 msgs (SiR,avd Eigersund
>amb)
>
>--__--__--
>
>Message: 1
>From: "Bjorn, Pret" <pbjorn@emh.org>
>To: "'trauma-list@trauma.org'" <trauma-list@trauma.org>
>Subject: RE: Hyperventilation of Head Trauma Patients
>Date: Fri, 2 May 2003 08:24:54 -0400
>Reply-To: trauma-list@trauma.org
>
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>Stephen,
>
>Good comments and excellent insights. Your throat has nothing to fear from
>me.
>
>Nonetheless, calling the actual ATLS teachings controversial is a stretch.
>They speak specifically to a very desperate scenario--a comatose patient
>whose clinical exam suggests a climbing ICP. Correct me, but I think even
>the BIF allows for brief and cautious hyperventilation as a last-ditch
>method to delay imminent herniation. Sad fact is, the primary injury has
>already charted the clinical course for such patients, and outcomes are
>probably unaffected either way.
>
>In all other cases, comprising the overwhelming majority of survivable
>brain
>injuries, eucapnea is advised. I've been to a lot of ATLS classes, and
>never heard or read otherwise.
>
>So. Academic differences of opinion? Maybe. But significant clinical
>controversy? I'm still doubtful.
>
>Pret
>
>-----Original Message-----
>From: Stephen R. [ <mailto:usafmedic45@hotmail.com>
>mailto:usafmedic45@hotmail.com]
>Sent: Thursday, May 01, 2003 12:20 PM
>To: trauma-list@trauma.org
>Subject: Hyperventilation of Head Trauma Patients: A Respiratory
>Therapist's two cents.
>
>
>I was reading the segment on ATLS recommendations and I could help but
>notice one glaring discrepancy: The recommendation to hyperventilate a head
>injured patient to a PaCO2 of 25-30 mmHg.
>
>As I am a respiratory therapist, for the love of God and the sake of your
>patients, listen to me on this. DO NOT (I REPEAT) DO NOT hyperventilate a
>traumatic brain injury to a PaCO2 or ETC02 of any less than 30-35 mmHg.
>Any
>lower and the antiswelling effect will be replaced by a vasoconstriction
>that will further choke off the blood supply to an already injured brain.
>Also you need to keep in mind that this hyperventilation effect only going
>to be effective for a few hours. I believe the literature says something
>like 12 hrs. It's been a while since I read the specifics. But anyhow by
>this time hopefully other measures will be able to instituted (i.e.
>surgery,
>etc.) much quicker than this. And for those of you who have RT departments
>who insist on bagging the patients instead of placing them on a ventilator,
>either make them bag nice and slow (a rate of 16 will lower PaCO2 faster
>than you think and give you an inhalation to exhalation (I:E) ratio of
>almost 1:4, (providing plenty of time for exhalation and prevent a build of
>intrinsic PEEP caused by breath stacking, which will have deleterious on a
>hypovolemic patient' hemodynamic status)) and/or make them use a electronic
>breath by breath capnograph that gives a numeric readout of the ETCO2
>instead of relying on those colorimetric ones. My opinion the use of
>electronic capnographs, despite their costs ($1,500-2,000 each) should
>become a standard of care, both in and out of hospital, for the ventilatory
>management of head trauma patients.
>
>This is my two cents. Any comments (lays throat bare)?
>
>Sincerely,
>Stephen L. Richey, CRT, EMT-I/D, ERT, FF
>
>
>
>_________________________________________________________________
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><DIV><FONT color=#800000 face=Arial size=2>Stephen,<BR><BR>Good comments
>and
>excellent insights. Your throat has nothing to fear from
>me.</FONT></DIV>
><DIV><FONT color=#800000 face=Arial size=2></FONT> </DIV>
><DIV><FONT size=2><FONT color=#800000 face=Arial>Nonetheless, calling the
>actual
>ATLS teaching<EM>s controversial </EM>is a stretch. They speak
>specifically to a very desperate scenario--a comatose patient whose
>clinical
>exam suggests a climbing ICP. Correct me, but I think even the BIF
>allows
>for brief and cautious hyperventilation as a last-ditch method to delay
>imminent
>herniation. Sad fact is, the primary injury has already charted the
>clinical course for such patients, and outcomes are probably unaffected
>either
>way.</FONT></FONT></DIV>
><DIV><FONT size=2><FONT color=#800000 face=Arial></FONT></FONT> </DIV>
><DIV><FONT size=2><FONT color=#800000 face=Arial>In all <EM>other
></EM>cases,
>comprising the overwhelming majority of survivable brain injuries,
>eucapnea
>is advised. I've been to a lot of ATLS classes, and never heard or
>read
>otherwise.</FONT></FONT></DIV>
><DIV> </DIV>
><DIV><FONT color=#800000 face=Arial size=2>So. Academic differences
>of
>opinion? Maybe. But significant clinical controversy? I'm
>still doubtful.</FONT></DIV>
><DIV> </DIV>
><DIV><FONT color=#800000 face=Arial size=2>Pret</FONT></DIV>
><DIV><FONT color=#800000 face=Arial size=2></FONT> </DIV>
><DIV><FONT color=#800000 face=Arial size=2><FONT
>color=#000000>-----Original
>Message-----<BR>From: Stephen R. [</FONT></FONT><A
>href="mailto:usafmedic45@hotmail.com"><FONT color=#000000 face=Arial
>size=2>mailto:usafmedic45@hotmail.com</FONT></A><FONT face=Arial
>size=2>]<BR>Sent: Thursday, May 01, 2003 12:20 PM<BR>To:
>trauma-list@trauma.org<BR>Subject: Hyperventilation of Head Trauma
>Patients: A
>Respiratory<BR>Therapist's two cents.<BR><BR><BR>I was reading the segment
>on
>ATLS recommendations and I could help but<BR>notice one glaring
>discrepancy: The
>recommendation to hyperventilate a head<BR>injured patient to a PaCO2 of
>25-30
>mmHg.<BR><BR>As I am a respiratory therapist, for the love of God and the
>sake
>of your<BR>patients, listen to me on this. DO NOT (I REPEAT) DO NOT
>hyperventilate a<BR>traumatic brain injury to a PaCO2 or ETC02 of any less
>than
>30-35 mmHg. Any<BR>lower and the antiswelling effect will be replaced
>by a
>vasoconstriction<BR>that will further choke off the blood supply to an
>already
>injured brain. <BR>Also you need to keep in mind that this
>hyperventilation
>effect only going<BR>to be effective for a few hours. I believe the
>literature says something<BR>like 12 hrs. It's been a while since I
>read
>the specifics. But anyhow by<BR>this time hopefully other measures
>will be
>able to instituted (i.e. surgery,<BR>etc.) much quicker than this.
>And for
>those of you who have RT departments<BR>who insist on bagging the patients
>instead of placing them on a ventilator,<BR>either make them bag nice and
>slow
>(a rate of 16 will lower PaCO2 faster<BR>than you think and give you an
>inhalation to exhalation (I:E) ratio of<BR>almost 1:4, (providing plenty of
>time
>for exhalation and prevent a build of<BR>intrinsic PEEP caused by breath
>stacking, which will have deleterious on a<BR>hypovolemic patient'
>hemodynamic
>status)) and/or make them use a electronic<BR>breath by breath capnograph
>that
>gives a numeric readout of the ETCO2<BR>instead of relying on those
>colorimetric
>ones. My opinion the use of<BR>electronic capnographs, despite their
>costs
>($1,500-2,000 each) should<BR>become a standard of care, both in and out of
>hospital, for the ventilatory<BR>management of head trauma
>patients.<BR><BR>This
>is my two cents. Any comments (lays throat
>bare)?<BR><BR>Sincerely,<BR>Stephen L. Richey, CRT, EMT-I/D, ERT,
>FF<BR><BR><BR><BR>_________________________________________________________________<BR>Protect
>your PC - get McAfee.com VirusScan Online <BR></FONT><A
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>face=Arial size=2>--<BR>trauma-list : TRAUMA.ORG<BR>To change your settings
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>--__--__--
>
>Message: 2
>Date: Fri, 02 May 2003 14:22:53 +0100
>Subject: Re: Nasopharyngeal Airways and severe maxillo-facial trauma and
> base of skull fracture
>From: Tim Coats <t.j.coats@qmul.ac.uk>
>To: <trauma-list@trauma.org>
>Reply-To: trauma-list@trauma.org
>
>I would use a nasopharyngeal airway almost routinely. Any medical
>intervention is a balance of risks and benefits. The risk of cranial
>penetration with a nasopharygeal airway is tiny (grateful for the
>references
>if anyone can provide case reports), so I judge that the benefits outweigh
>this risk.
>Tim.
>--
>Mr. T Coats
>Senior Lecturer in A&E / Pre-Hospital Care
>Barts and the London, Queen Mary's School of Medicine,
>University of London.
>
> > From: "Black, John" <John.Black@orh.nhs.uk>
> > Reply-To: trauma-list@trauma.org
> > Date: Fri, 2 May 2003 09:51:00 +0100
> > To: "'trauma-list@trauma.org'" <trauma-list@trauma.org>
> > Subject: Nasopharyngeal Airways and severe maxillo-facial trauma and
>base of
> > skull fracture
> >
> > I have major concerns re this widely quoted 'defensive' rationale for
> > avoiding NPA use in severe maxillo-facial trauma and base of skull
>fracture
> > based on rare anecdotal misadventure.
> >
> > What is not widely reported are the daily consequences of not using
>these
> > devices - of patients arriving in hospital hypoxic with significant
>airway
> > obstruction associated with trismus, despite the best endeavours of our
> > ambulance service colleagues with the resources that are currently
>available
> > to them.
> >
> > What clearly is crucial is that those inserting NPA are adequately
>trained
> > in basic facial anatomy and in insertion methodology.
> >
> > In my view, the ACS needs to urgently address the standard airway
>teaching
> > for this all too common scenario.
> >
> > I believe that these devices have a vital role in the initial airway
> > management of these patients.
> >
> > John Black
> > Emergency Medicine
> > Oxford,UK.
> >
> > -----Original Message-----
> > From: Holmes John [mailto:John_Holmes@mater.org.au]
> > Sent: 01 May 2003 02:26
> > To: 'trauma-list@trauma.org'
> > Subject: RE: Nasopharyngeal Airways
> >
> > Logically the same contraindications pertain to the use of
>Nasopharyngeal
> > airways as to NG tubes and nasal intubations - ie: contraindicated in
>basal
> > skull fracture and extensive faciomax trauma. The evidence for these
> > devices entering the anterior cranial fossa is rather anecdotal but
>prudence
> > would dictate avoiding the possibility.
> >
> > John
> >
> >
> >
> > Dr John L Holmes
> > Director Emergency Medicine
> > Mater Health Services
> > Brisbane, Australia
> >
> > -----Original Message-----
> > From: skip@c-d-m.com [mailto:skip@c-d-m.com]
> > Sent: Thursday, 1 May 2003 1:34
> > To: trauma-list@trauma.org
> > Subject: Nasopharyngeal Airways
> >
> > I am teaching First Responders and a question has come up about the use
>of
> > nasopharyngeal airways with maxillofacial trauma. The PHTLS textbook
>(5th
> > Ed) is silent on the use of this device in the presence of facial
>injuries
> > (ie if this is a relative contraindication), and a quick review of the
> > literature on PubMed does not show any case reports or studies of
>glaring
> > problems with NPA with respect to cranial penetration, etc.
> >
> > Does anyone have any comments on the NPA in the situation of
>maxillofacial
> > trauma with possible skull fracture (keeping in mind that First
>Responders
> > will not have the ability to intubate)?
> >
> > Thanks,
> >
> > Skip Tinnell, RN MSPH
> >
> >
> > --
> > trauma-list : TRAUMA.ORG
> > To change your settings or unsubscribe visit:
> > http://www.trauma.org/traumalist.html
> >
> >
> >
> >
> > --
> > trauma-list : TRAUMA.ORG
> > To change your settings or unsubscribe visit:
> > http://www.trauma.org/traumalist.html
> >
> >
> > --
> > trauma-list : TRAUMA.ORG
> > To change your settings or unsubscribe visit:
> > http://www.trauma.org/traumalist.html
> >
>
>
>
>
>--__--__--
>
>Message: 3
>From: "Terry Dinerman" <dinerman@computron.net>
>To: <trauma-list@trauma.org>
>Subject: Re: Nasopharyngeal Airways and severe maxillo-facial trauma
>andbase of skull fracture
>Date: Fri, 2 May 2003 07:49:25 -0700
>Reply-To: trauma-list@trauma.org
>
>This is a multi-part message in MIME format.
>
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>
>Dr's. Black, Coats, and Holmes........
>
>I can only offer anecdote to this thread........after 25 years providing =
>emergency medical services I have come to rely on the NPA, and =
>specifically the Robertassi style (very soft nitrile rubber with a =
>permanent fixed "trumpet" at the distal end) as my primary initial =
>airway adjunct in both trauma and medical patients. I find the =
>advantages of the NPA as follows:
>
>1- My Medical Directors approve of NPA as a primary airway adjunct.
>2- Less likely to provoke a gag reflex in the less than totally =
>unconscious patient or the patient returning to consciousness due to my =
>skillful oxygenation.
>3- Able to be deployed at an earlier stage due to #2.
>4- Will not dislodge dental appliances.
>5- Works in the presence of trismus.
>6- Will not cause oral trauma due to over-zealous insertion.
>7- Will not cause nasal trauma due to encountering obstructions or =
>over-zealous insertion. (Try to pierce a balloon with one......)
>8- Once inserted, it provides a route to suction the oropharynx in the =
>patient experiencing trismus. (Measure your soft catheter to mimic the =
>length of the NPA or just snug your yankaur tip up to a firm contact =
>with the distal end of the NPA.)
>9- It may remain in place during oral intubation attempts.
>10- It is already in place if an oral intubation attempt fails and =
>re-oxygenation must commence.
>11- Comes in a variety of fashionable colors. (So long as you like =
>"Hypoxia Blue")
>
>If enough facial trauma exists to physically bar the use of the NPA, I =
>will probably be suctioning vigorously and bagging as best I can and =
>then intubating immediately via standard, RSI or digital means or =
>considering a surgical intervention such as a Retrograde Intubation or =
>Surgical Cricothyrotomy if instrumented and digital techniques fail. =20
>
>(Tho trained, I have never had to employ my surgical training in the =
>field. After administering RSI drugs, I seem supernaturally lucky at =
>getting either an instrumented or digital placement of the ET.)
>
>If no facial trauma is present, I would employ a Combi-Tube if two nasal =
>intubation and two attempts at an RSI fail. (I will attempt nasal =
>intubation while my partner establishes IV access for the RSI drugs.)
>
>I have yet to find a body of literature that has frightened me or my =
>MD's enough to make us abandon the use of the NPA in the presence of =
>facial-maxillary trauma.........I believe the remarks about "prudence" =
>and "adequately trained in basic facial anatomy and insertion =
>methodology" are the keys to whatever dilemma exists regarding the use =
>of this device.=20
>
>Regards-
>
>
>Terry Dinerman EMTP
>
>
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><BODY bgColor=3D#ffffff>
><DIV><FONT face=3D"Comic Sans MS">Dr's. Black, Coats, and=20
>Holmes........</FONT></DIV>
><DIV><FONT face=3D"Comic Sans MS"></FONT> </DIV>
><DIV><FONT face=3D"Comic Sans MS">I can only offer anecdote to this=20
>thread........after 25 years providing emergency medical services I have =
>come to=20
>rely on the NPA, and specifically the Robertassi style (very soft =
>nitrile rubber=20
>with a permanent fixed "trumpet" at the distal end) as my primary =
>initial airway=20
>adjunct in both trauma and medical patients. I find the =
>advantages of=20
>the NPA as follows:</FONT></DIV>
><DIV><FONT face=3D"Comic Sans MS"></FONT> </DIV>
><DIV><FONT face=3D"Comic Sans MS">1- My Medical Directors approve of NPA =
>as a=20
>primary airway adjunct.</FONT></DIV>
><DIV><FONT face=3D"Comic Sans MS">2- Less likely to provoke a gag reflex =
>in the=20
>less than totally unconscious patient or the patient returning to =
>consciousness=20
>due to my skillful oxygenation.</FONT></DIV>
><DIV><FONT face=3D"Comic Sans MS">3- Able to be deployed at an =
>earlier stage=20
>due to #2.</FONT></DIV>
><DIV><FONT face=3D"Comic Sans MS">4- Will not dislodge dental =
>
>appliances.</FONT></DIV>
><DIV><FONT face=3D"Comic Sans MS">5- Works in the presence of=20
>trismus.</FONT></DIV>
><DIV><FONT face=3D"Comic Sans MS">6- Will not cause oral trauma due to=20
>over-zealous insertion.</FONT></DIV>
><DIV><FONT face=3D"Comic Sans MS">7- Will not cause nasal trauma =
>due to=20
>encountering obstructions or over-zealous insertion. (Try to pierce a =
>balloon=20
>with one......)</FONT></DIV>
><DIV><FONT face=3D"Comic Sans MS">8- Once inserted, it provides a =
>route to=20
>suction the oropharynx in the patient experiencing trismus. =
>(Measure your=20
>soft catheter to mimic the length of the NPA or just snug your yankaur =
>tip up to=20
>a firm contact with the distal end of the NPA.)</FONT></DIV>
><DIV><FONT face=3D"Comic Sans MS">9- It may remain in place during =
>oral=20
>intubation attempts.</FONT></DIV>
><DIV><FONT face=3D"Comic Sans MS">10- It is already in place if an oral =
>intubation=20
>attempt fails and re-oxygenation must commence.</FONT></DIV>
><DIV><FONT face=3D"Comic Sans MS">11- Comes in a variety of fashionable=20
>colors. (So long as you like "Hypoxia Blue")</FONT></DIV>
><DIV><FONT face=3D"Comic Sans MS"></FONT> </DIV>
><DIV><FONT face=3D"Comic Sans MS">If enough facial trauma exists to =
>physically bar=20
>the use of the NPA, I will probably be suctioning vigorously and bagging =
>as best=20
>I can and then intubating immediately via standard, RSI or digital means =
>or=20
>considering a surgical intervention such as a Retrograde Intubation or =
>Surgical=20
>Cricothyrotomy if instrumented and digital techniques =
>fail. =20
></FONT></DIV>
><DIV><FONT face=3D"Comic Sans MS"></FONT> </DIV><FONT face=3D"Comic =
>Sans MS">
><DIV><FONT face=3D"Comic Sans MS">(Tho trained, I have never had to =
>employ my=20
>surgical training in the field. After administering RSI=20
>drugs, I seem supernaturally lucky at getting either an =
>instrumented=20
> or digital placement of the ET.)</FONT></DIV>
><DIV> </DIV>
><DIV>If no facial trauma is present, I would employ a Combi-Tube =
>if two=20
>nasal intubation and two attempts at an RSI fail. (I will attempt nasal=20
>intubation while my partner establishes IV access for the RSI=20
>drugs.)</FONT></DIV>
><DIV><FONT face=3D"Comic Sans MS"></FONT> </DIV>
><DIV><FONT face=3D"Comic Sans MS">I have yet to find a body of =
>
>literature that has frightened me or my MD's enough to make us =
>abandon the=20
>use of the NPA in the presence of facial-maxillary trauma.........I =
>believe the=20
>remarks about "prudence" and "adequately trained in basic facial anatomy =
>and=20
>insertion methodology" are the keys to whatever dilemma exists regarding =
>the use=20
>of this device.</FONT><FONT face=3D"Comic Sans MS"> </FONT></DIV>
><DIV><FONT face=3D"Comic Sans MS"></FONT> </DIV>
><DIV><FONT face=3D"Comic Sans MS">Regards-</FONT></DIV>
><DIV><FONT face=3D"Comic Sans MS"></FONT> </DIV>
><DIV><FONT face=3D"Comic Sans MS"></FONT> </DIV>
><DIV><FONT face=3D"Comic Sans MS">Terry Dinerman EMTP</FONT></DIV>
><DIV><FONT face=3D"Comic Sans MS"></FONT> </DIV></BODY></HTML>
>
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>
>
>
>
>--__--__--
>
>Message: 4
>From: "Black, John" <John.Black@orh.nhs.uk>
>To: "'trauma-list@trauma.org'" <trauma-list@trauma.org>
>Subject: RE: Nasopharyngeal Airways and severe maxillo-facial trauma and b
> ase of skull fracture
>Date: Fri, 2 May 2003 16:13:43 +0100
>Reply-To: trauma-list@trauma.org
>
>This message is in MIME format. Since your mail reader does not understand
>this format, some or all of this message may not be legible.
>
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>Terry,
>
>An excellent synopsis!
>
>Points 2-8 you highlight are particularly relevant in most prehospital care
>systems where the resources for RSI and advanced airway management as you
>outline are simply not available until the patient reaches hospital.
>
>For the seriously injured in this part of the world (ISS>15), the
>prehospital phase of their care with a 'load and go' operational policy
>lasts on average 45 minutes, and, in entrapment situations is more likely
>to
>be 1-2 hours.
>
>Best wishes,
>
>John Black
>Emergency Medicine
>Oxford, UK
>
>-----Original Message-----
>From: Terry Dinerman [mailto:dinerman@computron.net]
>Sent: 02 May 2003 15:49
>To: trauma-list@trauma.org
>Subject: Re: Nasopharyngeal Airways and severe maxillo-facial trauma
>andbase
>of skull fracture
>
>Dr's. Black, Coats, and Holmes........
>
>I can only offer anecdote to this thread........after 25 years providing
>emergency medical services I have come to rely on the NPA, and specifically
>the Robertassi style (very soft nitrile rubber with a permanent fixed
>"trumpet" at the distal end) as my primary initial airway adjunct in both
>trauma and medical patients. I find the advantages of the NPA as follows:
>
>1- My Medical Directors approve of NPA as a primary airway adjunct.
>2- Less likely to provoke a gag reflex in the less than totally unconscious
>patient or the patient returning to consciousness due to my skillful
>oxygenation.
>3- Able to be deployed at an earlier stage due to #2.
>4- Will not dislodge dental appliances.
>5- Works in the presence of trismus.
>6- Will not cause oral trauma due to over-zealous insertion.
>7- Will not cause nasal trauma due to encountering obstructions or
>over-zealous insertion. (Try to pierce a balloon with one......)
>8- Once inserted, it provides a route to suction the oropharynx in the
>patient experiencing trismus. (Measure your soft catheter to mimic the
>length of the NPA or just snug your yankaur tip up to a firm contact with
>the distal end of the NPA.)
>9- It may remain in place during oral intubation attempts.
>10- It is already in place if an oral intubation attempt fails and
>re-oxygenation must commence.
>11- Comes in a variety of fashionable colors. (So long as you like
>"Hypoxia
>Blue")
>
>If enough facial trauma exists to physically bar the use of the NPA, I will
>probably be suctioning vigorously and bagging as best I can and then
>intubating immediately via standard, RSI or digital means or considering a
>surgical intervention such as a Retrograde Intubation or Surgical
>Cricothyrotomy if instrumented and digital techniques fail.
>
>(Tho trained, I have never had to employ my surgical training in the field.
>After administering RSI drugs, I seem supernaturally lucky at getting
>either
>an instrumented or digital placement of the ET.)
>
>If no facial trauma is present, I would employ a Combi-Tube if two nasal
>intubation and two attempts at an RSI fail. (I will attempt nasal
>intubation
>while my partner establishes IV access for the RSI drugs.)
>
>I have yet to find a body of literature that has frightened me or my MD's
>enough to make us abandon the use of the NPA in the presence of
>facial-maxillary trauma.........I believe the remarks about "prudence" and
>"adequately trained in basic facial anatomy and insertion methodology" are
>the keys to whatever dilemma exists regarding the use of this device.
>
>Regards-
>
>
>Terry Dinerman EMTP
>
>
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><body bgcolor=3Dwhite lang=3DEN-US link=3Dblue vlink=3Dpurple =
>style=3D'tab-interval:36.0pt'>
>
><div class=3DSection1>
>
><p class=3DMsoNormal><font size=3D2 color=3Dnavy face=3DArial><span =
>style=3D'font-size:
>10.0pt;font-family:Arial;color:navy'>Terry,<o:p></o:p></span></font></p>=
>
>
><p class=3DMsoNormal><font size=3D2 color=3Dnavy face=3DArial><span =
>style=3D'font-size:
>10.0pt;font-family:Arial;color:navy'><o:p> </o:p></span></font></p>=
>
>
><p class=3DMsoNormal><font size=3D2 color=3Dnavy face=3DArial><span =
>style=3D'font-size:
>10.0pt;font-family:Arial;color:navy'>An excellent =
>synopsis!<o:p></o:p></span></font></p>
>
><p class=3DMsoNormal><font size=3D2 color=3Dnavy face=3DArial><span =
>style=3D'font-size:
>10.0pt;font-family:Arial;color:navy'><o:p> </o:p></span></font></p>=
>
>
><p class=3DMsoNormal><font size=3D2 color=3Dnavy face=3DArial><span =
>style=3D'font-size:
>10.0pt;font-family:Arial;color:navy'>Points 2-8 you highlight are =
>particularly relevant
>in most prehospital care systems where the resources for RSI and =
>advanced
>airway management as you outline are simply not available until the =
>patient
>reaches hospital.<o:p></o:p></span></font></p>
>
><p class=3DMsoNormal><font size=3D2 color=3Dnavy face=3DArial><span =
>style=3D'font-size:
>10.0pt;font-family:Arial;color:navy'><o:p> </o:p></span></font></p>=
>
>
><p class=3DMsoNormal><font size=3D2 color=3Dnavy face=3DArial><span =
>style=3D'font-size:
>10.0pt;font-family:Arial;color:navy'>For the seriously injured in this =
>part of
>the world (ISS>15), <span =
>style=3D'mso-spacerun:yes'> </span>the
>prehospital phase of their care with a 'load and go' operational
>policy lasts on average 45 minutes, and, in entrapment situations is =
>more
>likely to be 1-2 hours.<o:p></o:p></span></font></p>
>
><p class=3DMsoNormal><font size=3D2 color=3Dnavy face=3DArial><span =
>style=3D'font-size:
>10.0pt;font-family:Aria
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