Airway Chapters 1 & 2

Here are a couple thoughts out of a book I'm reading currently, The Manual of Emergency Airway Management:

"The gag reflex is of no clinical value when assessing the need for intubation."

-Ron M. Walls

In school I was taught the gag reflex was a way of measuring if an obtunded patient could maintain and protect their own airway. I have heard some conflicting information on that in the past few years, but Dr. Walls lays it out there pretty clearly and examines multiple studies that have shown that there is no correlation between the gag reflex and the proper functioning of someone's airway protective mechanisms. He further mentions the logical conclusion that testing the gag reflex may cause vomiting which only makes the situation worse. Walls suggests that perhaps a better sign is noting if there are any secretions in the mouth or airway that the patient has not swallowed.

What are you using to determine a patient's ability to protect their own airway? How can we translate this information into the prehospital setting?

The Obtunded Patient: Pretreat vs. No Pretreatment

Thinking specifically in obtunded overdose patients. Some of the medics I work with have brought up good questions about the use of our typical pretreatment medications (usually Etomidate and Succinylcholine) asking the question of whether they're necessary or not. I'm open to suggestions, and my thought is 1. If I was being intubated, I'd rather be over-sedated than under-sedated and 2. I choose to use paralytics to give myself the best chance of success during the intubation. Wall reviews a few studies on deeply sedated patients and withholding neuromuscular blockers during RSI in these patients. Each study had similar results, and in one study as many as 70% of these patients "demonstrated unacceptable intubating conditions with vocal cords either adducted or closing, excessive patient movement, or sustained coughing." What are your thoughts?