ET Tubes Should Maintain, Not Fix

On EMS Office Hours, Jim Hoffman JD Graziano (co-host of EMS Standing Orders) discussed how “always” and “never” protocols hinder good airway management. One such protocol is the ridiculous “intubate if GCS is less than 8,”  and another is to never use nasal intubation.

JD discussed how he managed the airway of CVA patient with clenched teeth who was vomiting.  With supplemental oxygen and suction around the clenched teeth, he was able to maintain the patient’s pulse-ox above 95% during transport.

Some misguided paramedics would have spent 45 minutes trying to jam a tube down this patient’s throat.  Some less informed medical directors and QI officers would chastise a paramedic who did not intubate someone with a GCS less than 8.

In the big picture of airway management, patients need adequate oxygenation, ventilation, and protection.  Now we know that an ET tube can make all of these worse,  which is why they may be gone soon.  Oxygenation, ventilation, and protection issues should be corrected with less invasive tools first.  Only then, in the right circumstances, should an ET tube be placed to maintain what has been fixed. The benefits of placing the tube must clearly outweigh the risks, and the hospital should still be a considerable distance away.   Usually good enough should be left alone.

There are extremely rare occasions when oxygenation, ventilation, and protection can not be managed with the basics.   For extremely large patients, patients with facial injuries, or patients who have such a large amount of secretions that they can not be suctioned, the only options to achieve these goals are through the nose or the neck.  This is when nasal intubation or a crich are needed.

We need to move past one size fits all approaches to airway management.  We need to be able to see what patient’s need most, and recognize when our interventions can harm.  And with the most critical patients, we should not need to ask permission to act.



  1. Pulse Oximetry readings are not an indicator of clinical anything. What Hoffman doesn’t know and won’t know (most likely) is how much vomitus he blew down into the patient’s lungs and if there was a resultant aspiration pneumonia.

    Which as you SHOULD know has a very high mortality rate. There’s a reason why anesthesiologists are so paranoid about peri operative patient vomiting and require them to be NPO for at least 8 hours unless it’s emergency surgery.

    The head trauma patient I transported the other night needed to be sedated, paralyzed, and intubated because he couldn’t protect his airway and had blood and teeth already in it. On the other hand, the patient I transported this morning who was unconscious could be maintained with an OPA and BVM, although he got intubated in the ED. The difference is in knowing when intubation is needed and when it’s not.

    To say that it’s extremely rare when airway can not be managed with BLS skills is simplistic at best. Patients who can’t protect their own airway generally need intubation. Sometimes that can be managed in the field with BLS skills, but often it requires intubation.

    • emspatientperspective says:

      Of course aspiration is bad, and of course patients with clenched teeth need to be intubated. The question is whether or not they should be intubated by us, given the tools available and the distance to the hospital. Our patients get in trouble when intubation is done at the expense of oxygenation. More than a few patients in San Diego were hurt from prolonged periods of hypoxia during intubation, and this was captured with archived pulse-ox trends.

      If you heard the podcast, it was JD’s call that they were discussing. After rescuing the patent’s sat, he did not have RSI available. His dilemma was whether or not to do a nasal intubation, which would have required permission from medical control. I agree with his decision not to intbuate.

      My point is that patients need to be oxygenated, ventilated, and suctioned before anyone thinks about intubating. If oxygenation is not possible, which for skilled people is extremely rare, then a tube needs to go in their nose or neck.

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