Editor’s Note: CapnoStories are reports from the field written by real EMS providers. They are not necessarily reflective of the views of CapnoAcademy.

By Dominick Walenczak

What was the patient’s problem? Describe your assessment findings and the patient’s presentation.

We just cleared another call and were dispatched to a call for an unresponsive patient. On our arrival, we were told by the first responders that “It’s bad, Dom. You need to get in there with your drug bag!” But… I need… all this. Anyways, we make patient contact and find a 68 YOF with a NRB mask on. Husband reports that she had appeared fine and they were making plans to go out this morning. He went to get his shoes and came back to find her collapsed face down on the kitchen table. Patient had an improvement in mental status with some supplemental oxygen. Her only utterance was “I’m going to die. I’m going to die.” Her lungs were clear as a bell. Initial SpO2 in the 70’s with a NRB mask. Shortly thereafter, the patient once again went unresponsive.

How did you treat the patient?

We immediately directed the positive pressure ventilations of this patient via BVM as our stretcher and backboard were brought in. The backboard, of course, not being for spinal precautions. But provider judgement, aka “spidey senses”, was saying that this was likely to become a cardiac arrest. Closest facility was notified to make preparations. As the patient was lifted from her chair at the kitchen table and placed on the board/stretcher, we also prepared for an immediate intubation. Difficulty obtaining a blood pressure at this time. However, before intubation could be performed, the patient had a return of consciousness and was pushing away the BVM. The patient was moved out of the townhouse on the stretcher to the ambulance, but due to the narrow corridor and entranceway, as well as patient pushing away the BVM, no ventilations were delivered coming out of the house. By the time we got to the ambulance, patient was once again unresponsive. And now bradycardic too at 40 bpm.

“Let’s resume ventilations quickly.” Well, more like promptly. But you know what I mean.

IV access was established and a BP was obtained at 70/40. Our service has no provision for RSI. An with a considerably low blood pressure, it was felt that Midazolam would be too risky to use. Because every time the patient had a slight improvement in mental status, she would push away the BVM and lapse back into unconsciousness, it was felt that the airway needed to be controlled and secured then and there. However, there was still too much muscle tone around the mouth to facilitate traditional endotracheal intubation via direct laryngoscopy.

So, the only option left to use was nasotracheal intubation. Our service is equipped with a BAAM device, which is essentially a whistle tip to time your blind nasotracheal tube advancement. But then, and idea clicked in my head. Rather than use the BAAM, our service was also equipped mainstream EtCO2 monitoring, which allowed us to monitor inspiration and expiration in near real time. So, after a bit of Hurricaine Spray, we were off and advancing our 7.0 ETT into the nose of our patient. After a few centimeters of advancement past the nasopharynx, we still had a good capnographic waveform, so we applied a BURP maneuver and gave and mighty shove timed with the EtCO2 waveform. It sounds crude and unsophisticated, but that does succinctly sum up the procedure of nasal intubation.

What improvements or changes did you observe?

Afterwards, we had all the air coming out of her tube and none out of the nose/mouth. We still had a good waveform and good bilateral lung sounds. Fire personnel had commentary along the lines of “Whoa! I’ve never seen anyone do that before! That was so cool!”

“Whoa, me neither! That actually worked!” is what I wanted to add. And what I was saying on the inside. But externally, I had to keep my professional cool and opted for a more nonchalant “It’s a seldom used alternate method.”

We transported to the closest facility. During this time, the SpO2 had come up to around 90%, but the EtCO2 hovered ominously around 20, even with slow, controlled ventilations via BVM. This was concerning and suggestive of PE as the probable culprit for our patient’s extremis.

What are your lessons learned for other clinicians?

Thomas tube holders weren’t designed for, nor do they really work for, nasal intubations. Make sure you hold on to your tube personally. Because there’s nothing worse than hearing “Hey, um, this thing came off with the BVM” and see the end of the tube disappear up the end of the patient’s nose. Magill Forceps and pulling on the pilot balloon got the tube back out, but it is still an unpleasant experience — and I bet none too comfortable for the patient either.

This patient coded briefly upon transfer to the ED (PEA, but likely just profoundly hypotensive). She was resuscitated, RSI’d, and sent for stat CT, where they found a large left sided PE (almost a saddle PE). The patient underwent a thrombectomy, which was successful. Unfortunately, she passed from post procedure complications.