Allegedly the biggest myth taught in medical school?

A few senior doctors on here mentioned about GCS and airway protection being overblown.

When exactly in a peri-arrest situation (i am assuming new onset reduced GCS, unconscious patient, post seizure etc) would you be putting in an airway adjunct?

Reply 1

nexttime

22

Original post by Anonymous

A few senior doctors on here mentioned about GCS and airway protection being overblown.

When exactly in a peri-arrest situation (i am assuming new onset reduced GCS, unconscious patient, post seizure etc) would you be putting in an airway adjunct?

If they tolerate it, then sure. I certainly wouldn't stand around calculating out an exact GCS to base my decision on - I've never seen that taught anywhere.

Are you asking whether this is the biggest the medical myth, or stating it? :tongue:

Reply 2

Anonymous #1

OP

Original post by nexttime

If they tolerate it, then sure. I certainly wouldn't stand around calculating out an exact GCS to base my decision on - I've never seen that taught anywhere.

Are you asking whether this is the biggest the medical myth, or stating it? :tongue:

Haha, maybe both!

Would you consider putting in a OPA in the following?:

1. During seizure reduced GCS < 8
2. GCS < 9
3. GCS < 8
4. If a patient appeared to be having stridor and not anaphylaxis/suction did not help

Reply 3

Spencer Wells

12

Original post by Anonymous

When exactly in a peri-arrest situation (i am assuming new onset reduced GCS, unconscious patient, post seizure etc) would you be putting in an airway adjunct?

When their upper airway isn't patent. Signs of this include grunting and snoring sounds, or see-saw moving of the abdomen during respiration. This isn't necessarily related to level of consciousness (although a patient with depressed consciousness is more likely to have upper airways obstruction, due to decreased conscious ability to cough/clear secretions, and floppy tongue/pharyngeal musculature impinging upon the airway)

GCS is a crude tool, widely applied outside of the situation in which it was developed, and it is not a case that there isa. magical cut-off of 8, above which your airway is definitely safe and below which it is not.
Consciousness (and airway protection, again with the caveat that this relationship is not linear) is a continuous spectrum and is not best divided into 13 arbitrary points from 3 to 15.
If you really want to understand this practically then become an anaesthetist.

Reply 4

Anonymous #1

OP

Original post by Spencer Wells

When their upper airway isn't patent. Signs of this include grunting and snoring sounds, or see-saw moving of the abdomen during respiration. This isn't necessarily related to level of consciousness (although a patient with depressed consciousness is more likely to have upper airways obstruction, due to decreased conscious ability to cough/clear secretions, and floppy tongue/pharyngeal musculature impinging upon the airway)

GCS is a crude tool, widely applied outside of the situation in which it was developed, and it is not a case that there isa. magical cut-off of 8, above which your airway is definitely safe and below which it is not.
Consciousness (and airway protection, again with the caveat that this relationship is not linear) is a continuous spectrum and is not best divided into 13 arbitrary points from 3 to 15.
If you really want to understand this practically then become an anaesthetist.

This was quite an interesting read.

I've seen a lot of senior registrars in emergency situations , as well as consultants put in OPAs in patients during/post seizures, reduced GCS (normally 3).

In terms of grunting and snoring, would you go for a suction first, and then try an OPA, or NPA?

Reply 5

Anonymous #1

OP

I am also assuming that in any cardiac arrest, an airway adjunct should be placed with 15L oxygen attached to it via a bag valve mask, and in a patient who is breathing , with a non-re breathable if there's an airway adjunct.

It's late so i may have mistyped something.

Reply 6

fishfacesimpson

9

Original post by Spencer Wells

When their upper airway isn't patent. Signs of this include grunting and snoring sounds, or see-saw moving of the abdomen during respiration. This isn't necessarily related to level of consciousness (although a patient with depressed consciousness is more likely to have upper airways obstruction, due to decreased conscious ability to cough/clear secretions, and floppy tongue/pharyngeal musculature impinging upon the airway)

GCS is a crude tool, widely applied outside of the situation in which it was developed, and it is not a case that there isa. magical cut-off of 8, above which your airway is definitely safe and below which it is not.
Consciousness (and airway protection, again with the caveat that this relationship is not linear) is a continuous spectrum and is not best divided into 13 arbitrary points from 3 to 15.
If you really want to understand this practically then become an anaesthetist.

I agree. I am not an emergency physician but I guess the point is when deciding whether the airway needs support - assess the airway. That's why it's A, first in the list. If you are worried about the airway do something about it.

In some situations, GCS can correlate with likelihood of losing airway patency but GCS does not define the airway. You can have GCS 15 with a neuromuscular problem causing bulbar weakness and be on the cusp of respiratory arrest. The danger with reliance on the GCS is that situations like that get overlooked until extremis/arrest.

Reply 7

nexttime

22

Original post by Anonymous

Haha, maybe both!

Would you consider putting in a OPA in the following?:

1. During seizure reduced GCS < 8
2. GCS < 9
3. GCS < 8
4. If a patient appeared to be having stridor and not anaphylaxis/suction did not help

As a lowly non-anaesthetist, calculating a GCS still takes me like a minute or two so in a real emergency I wouldn't be doing that until way later anyway. I would put in an airway if I was worried about the airway. And yes that would include a full arrest.

Reply 8

Spencer Wells

12

Original post by Anonymous

In terms of grunting and snoring, would you go for a suction first, and then try an OPA, or NPA?

I would firstly perform a jaw thrust with a bit of head tilt/chin lift, while applying oxygen via facemask, as I was waiting for suction to be available (outside of theatres/ITU, it is often not connected and the consumables aren't always there and so it can take some time to put together).

Original post by Anonymous

I am also assuming that in any cardiac arrest, an airway adjunct should be placed with 15L oxygen attached to it via a bag valve mask, and in a patient who is breathing , with a non-re breathable if there's an airway adjunct.

In a cardiac arrest, if available, a second-generation supraglotic airway should be inserted (in the UK the igel brand of laryngeal mask airway is the one stocked on most crash trolleys) and this should be attached to both capnography and a self-inflating bag/valve/mask which is attached to a free-flowing oxygen supply which is capable of delivering oxygen at 15L/min or more.

If you are inserting any airway adjunct you almost certainly want to be delivering supplemental oxygen, and in the first instance this would be via a NRB mask with high-flow oxygen, as you then carry on your assessment and treatment of the patient, until the appropriate people arrive to modify that plan, if necessary.

Reply 9

Etomidate

15

In a non-arrest, if a newly unconscious patient is no longer able to talk to you, you will do no harm putting an oral airway in (assuming you don’t smash their teeth out). If they spit it out, fine. It’s also a good test of how unconscious a patient is, and can be a good stimulus to wake some patients up a little.

Nasal airways are more tolerated but will almost always cause a nosebleed.

I would only suction if you can hear rattly secretions in the upper airway.

In a cardiac arrest, if you’ve done ALS you should be able to place a supraglottic airway like an igel. If you are not comfortable doing that, use a guedel and a BVM.

Don’t worry about calculating a GCS to decide your airway management. Just consider the signs mentioned already in this thread.

(edited 3 years ago)

Allegedly the biggest myth taught in medical school?

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