To paralyze or not to paralyze

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So I got screamed at by a gas passer yesterday when discussing RSI and wanted some other opinions. I have asked around many practitioners and both sides of the argument seem to make sense but I can't get a good feel for where EM should sit.

Anesthesia
No reason to paralyze the vast majority of pts. If they are breathing on their own (even if its not enough) no matter what, they will be able to oxy/vent and can always be bagged. Its not that hard to tube a tired pt with only sedation, and thus paralysis can only cause problems as there is a risk of side effects and if you can't ventilate you are in trouble.

EM
When you decide to intubate its because they need a definitive airway. Thus, no matter what happens, you are going to be securing some sort of airway. Sedate and paralyze with sux or roc and don't stop until airway is secure. If can't intubate/cant ventilate and pt is crashing = cric or equivalent. Pts come in and are in an uncontrolled setting, who the heck knows how they will react. Paralysis=less vomit and a more controlled experience.


When I argued this with anesthesia they say that only a handful of pt every really need paralysis, which actually makes some sense to me. But nearly every tube in the ED gets paralyzed, perhaps only out of habit.

Had this come up with a huge CHF pt. Guy was nearly 500lbs and was dying that second. Airway was a disaster, swollen and tons of secretions, but he was technically breathing on his own. He was paralyzed and O2 dropped like a rock. Face/tongue was so big that it was really tough to bag even with an oral airway. kept bouncing off chords followed by an esophageal intubation. Eventually, glidescope was used and airway was secured, but the guy was super hypoxic for quite some time. I keep second guessing the decision to paralyze him.

Any thoughts?

Those are the guys that you could and should do a delayed sequence intubation and take your time with so that you dont get into a crash situation. Bipap and ketamine/versed to preoxygenate prior to tube work wonders!

Anesthesiology doesn't work in the ED. That's where the difference in opinion comes from. Sure, most tubes might not need paralytics, but all of our tubes are emergent and paralytics increase the success of intubation.

That is exactly the patient I would want to paralyze to maximize my chance to successfully intubate on the 1st try. However, I also agree with Greenbbs, with the caveat that I'd take a 1st look - if no go on 1st look, I'd place an LMA, get 'em to 100% (or as close as I can) and then take a second look.

If you sedate that guy without paralysis, where are you when the meds wear off? You've got a guy who still needs a tube!

On a side note - I hope you ramped this guy. He is not a patient I would lay fully supine, as that's going to let all the weight of his belly restrict his diaphragm. If you gave him the meds and then layed him flat - that's why his sats dropped so fast.

In this specific case he was on bipap and propped up, but i don't think it really made a difference. In the end, not paralyzing him may have made the placement a little simpler and could have bought me some more time with the bag. But its all hindsight. I don't really have a problem with paralysis in most cases as I feel that eventually an airway of some sort can be placed. In any young otherwise healthy person I see no issue with it. That said, most ICUs I have been in have essentially a no paralysis policy. The rational seems to be that its a little bit more controlled and they are older/sicker than an OD that needs airway protection thus time is on your side. I question paralysis when a pt will have an obvious difficult airway and can somewhat agree with anesthesia in regards to buying you more time to bag. Fat old CHF seems to be where I am uncertain of. In a skinny COPDer, who cares? The airway will get placed.

Originally Posted by danzman

In this specific case he was on bipap and propped up, but i don't think it really made a difference. In the end, not paralyzing him may have made the placement a little simpler and could have bought me some more time with the bag. But its all hindsight...

I'm not sure why you think that not using a paralytic makes someone easier to bag???

Originally Posted by danzman

In this specific case he was on bipap and propped up, but i don't think it really made a difference. In the end, not paralyzing him may have made the placement a little simpler and could have bought me some more time with the bag. But its all hindsight. I don't really have a problem with paralysis in most cases as I feel that eventually an airway of some sort can be placed. In any young otherwise healthy person I see no issue with it. That said, most ICUs I have been in have essentially a no paralysis policy. The rational seems to be that its a little bit more controlled and they are older/sicker than an OD that needs airway protection thus time is on your side. I question paralysis when a pt will have an obvious difficult airway and can somewhat agree with anesthesia in regards to buying you more time to bag. Fat old CHF seems to be where I am uncertain of. In a skinny COPDer, who cares? The airway will get placed.

Fat, short necked patients with minimal respiratory reserve are people I want the tube in as fast as possible. In my experience (read: as a sr resident, not an attending), the longer you take putzing around in the airway, the more likely the patient is to start vomiting. The only thing worse than tubing the fat/no necked/Sao2 in 80s on O2 is tubing him when he's vomiting all over the place. I've had several such tubes working at a "FatGuy/No Neck Center of Excellence" and afterwards I usually think "damn, if I'd just got that tube in a little faster I could have avoided that".

I would also say that the "can't intubate/can't ventilate" situation is far far more rare than the "jaw clenched because of inadequate paralysis" or "vomiting because of too much bagging".

Originally Posted by Zanegray

I'm not sure why you think that not using a paralytic makes someone easier to bag???

If anything, I'd say it's the opposite. Bagging someone who is clenching their jaw is pretty difficult - intubating them is even harder!

Originally Posted by Cerberus

Fat, short necked patients with minimal respiratory reserve are people I want the tube in as fast as possible. In my experience (read: as a sr resident, not an attending), the longer you take putzing around in the airway, the more likely the patient is to start vomiting. The only thing worse than tubing the fat/no necked/Sao2 in 80s on O2 is tubing him when he's vomiting all over the place. I've had several such tubes working at a "FatGuy/No Neck Center of Excellence" and afterwards I usually think "damn, if I'd just got that tube in a little faster I could have avoided that".

I would also say that the "can't intubate/can't ventilate" situation is far far more rare than the "jaw clenched because of inadequate paralysis" or "vomiting because of too much bagging".



If anything, I'd say it's the opposite. Bagging someone who is clenching their jaw is pretty difficult - intubating them is even harder!

agree with all of this. having worked in an environment where paralytics were not available I can tell you that in the vast majority of cases things worked much better with paralysis than without. that being said, for a known difficult airway I would look at other options depending on the condition of the patient....I've seen some ED docs who were trained well with fiberoptics place tubes on near impossible airways with ease in awake patients.

OP--thanks for arguing on our behalf. It's well studied that paralytics provide more ideal intubating conditions and allow you to rapidly proceed through the algorithm as needed.

For the vast majority of our patients getting intubated in the ED, an ETT tube = Life. For those, you have to give them and you the best shot. Our patients haven't been NPO and pre-oxygenating for the past week like those in the OR. We tube people who are vomiting, have massive ICPs, trauma, EtOH or other ingestions, or a glamor shot for the bariatric surgery industry.

With that said, there's some people that I try to do awake. I've done nasal fiberoptic for bad angioedema or awake with ketamine for the profoundly acidotic patient breathing 50/min

Originally Posted by Zanegray

I'm not sure why you think that not using a paralytic makes someone easier to bag???

Maybe I didn't state that correctly. In the gas passers argument, this guy was at the very least breathing on his own. Upon putting him down, his size, girth and secretions made it difficult to bag but certainly not impossible. We were able to reposition, re-asses, and pump his sats back up eventually, but that was after a failed attempt. Not really a big deal, and like I said, in this situation I don't think it changed anything at all. Guy got his airway and went upstairs. Their argument is that, for whatever reason you couldn't bag him, you would be in trouble. I would also say that paralytics make combative or anxious pts easier to bag. But when I say this to anesthesia they will say that enough benzos/opiates could be also used just as effectively. I'm on our side with this. I just find it interesting that the two fields that like to claim the "master of the airway" title seem to have different opinions about this. I am far to early on in a career to know anything really, just looking for opinions.

Originally Posted by danzman

Maybe I didn't state that correctly. In the gas passers argument, this guy was at the very least breathing on his own. Upon putting him down, his size, girth and secretions made it difficult to bag but certainly not impossible. We were able to reposition, re-asses, and pump his sats back up eventually, but that was after a failed attempt. Not really a big deal, and like I said, in this situation I don't think it changed anything at all. Guy got his airway and went upstairs. Their argument is that, for whatever reason you couldn't bag him, you would be in trouble. I would also say that paralytics make combative or anxious pts easier to bag. But when I say this to anesthesia they will say that enough benzos/opiates could be also used just as effectively. I'm on our side with this. I just find it interesting that the two fields that like to claim the "master of the airway" title seem to have different opinions about this. I am far to early on in a career to know anything really, just looking for opinions.

It sounds like he was already in trouble upon arrival--the main fallacy in the anesthesia argument is the assumption that if we run into airway trouble that we can just wake our patients up, as if the induction agent is some magical elixir that cures their root cause of respiratory distress.

Originally Posted by Tiger26

It sounds like he was already in trouble upon arrival--the main fallacy in the anesthesia argument is the assumption that if we run into airway trouble that we can just wake our patients up, as if the induction agent is some magical elixir that cures their root cause of respiratory distress.

Absolutely!

I think it's pretty simple. Vast majority of literature shows RSI increases our chance of successful attainment of definitive airway in the ED...period. We don't have the luxury of having NPO past midnight and the ability to cancel intubation "cases" if say... the glucose is too high. Our pt's have eaten 4 big macs and 40oz of diet coke 10 minutes prior to arrival in respiratory distress and I don't know about you but I don't want to deal with that kind of aspiration. Obviously there are cases when we don't want to paralyze but the majority of time we do it for a reason and I think very few anesthesiologist have a pure grasp of the conditions surrounding the majority of our intubation scenarios in the ED.

I respect their opinion greatly and I think we all can learn a thing or two from them but totally disagree with that statement if he was implying we shouldn't be paralyzing patients for intubation attempts in the ED. I'm kind of surprised by that. Our anesthesiologists are more on board with our approach during the infrequent visits to the ED where we can actually discuss airway stuff. (Once a year or so...)

Originally Posted by WilcoWorld

Anesthesiology doesn't work in the ED. That's where the difference in opinion comes from. Sure, most tubes might not need paralytics, but all of our tubes are emergent and paralytics increase the success of intubation.

This is the best statement that describes my stance on it.

If I sense it's going to be a difficult airway (very obese, short neck, big tongue, etc.), then I sometimes sedate without paralytics and attempt to pass the tube. A lot of times I can do it, but occasionally I visualize the cords and can't get enough relaxation to pass the tube. Perhaps I'm underdosing the etomidate.

I've gotten quite used to etomidate and rocuronium for RSI.

It's all about predicting bad airways. Pee poor planning will always lead peeing in your pants when they're crashing.

Originally Posted by danzman

Maybe I didn't state that correctly. In the gas passers argument, this guy was at the very least breathing on his own. Upon putting him down, his size, girth and secretions made it difficult to bag but certainly not impossible. We were able to reposition, re-asses, and pump his sats back up eventually, but that was after a failed attempt. Not really a big deal, and like I said, in this situation I don't think it changed anything at all. Guy got his airway and went upstairs. Their argument is that, for whatever reason you couldn't bag him, you would be in trouble. I would also say that paralytics make combative or anxious pts easier to bag. But when I say this to anesthesia they will say that enough benzos/opiates could be also used just as effectively. I'm on our side with this. I just find it interesting that the two fields that like to claim the "master of the airway" title seem to have different opinions about this. I am far to early on in a career to know anything really, just looking for opinions.

It's been my experience that patients such as CHF'ers, COPD'ers, and asthmatics that require intubation are often so tired by the time they come to the ED and need intubation that just a little sedation will often make them apneic. In other words, they wouldn't be breathing on their own with or without paralytics. The paralytics at least allows the jaw muscles to relax more so you can visualize the cords better.

I'm surprised myself. At my training institution, when anaesthesia got involved (semi-elective cases when the department was busy), they would RSI in majority of situations themselves. The only semi-elective tube they didn't do it on was an angioedema case where they did an awake intubation.

A patient with those demographics should ideally have an awake intubation performed. But in the heat of battle and when you need it done now, there really isn't time to topicalize them w/ anaesthesia and they won't be relaxed enough to tolerate the procedure. Paralyzing patients very clearly has been shown to increase your chance of successful intubation, which is, in fact, the goal. Ideally we would like to do it without hypoxia. Placing a laryngoscope in a non-paralyzed patient's mouth is 1) more likely to have suboptimal view 2) more likely to induce vomiting. If I can think of 2 ways to make this sick patient worse they are 1) unable to intubate due to poor visualization or 2) vomit in the airway. This is why EM physicians generally do RSI. Don't sweat the anesthesiologists - they are experts at elective airway management. Intubating in the resuscitation room is our forte and area of expertise. Intubating the crashing patient is always going to be a challenge - everyone's going to have a quarterback opinion on it.

I am as perplexed as the others about why you would be "screamed" at by an anesthesiologist about RSI...If it was over this particular case or a similar one I may be able to imagine their point. But, as has been stated, RSI allows for optimization of your first look, which you want to be your best look. In general I am huge fan of RSI and use it regularly. It is clearly the preferred method for dealing with the full stomach as well, and we have to assume that is the vast majority of our patients. Also, full induction doses of sedation in all but maybe dexmedetomidine and ketamine will regularly result in respiratory depression to the point of apnea in the sick patients that we tube, thus negating any advantage to sedation alone. I have even seen someone go apeneic with ketamine, for what it’s worth. Therefore, the general argument against RSI in the ED seems odd. My sense is, and I may be wrong, that this anesthesiologist was either discussing a specific case or is outside the mainstream.

The obese, CHFer with no oxygen reserve are some of the toughest airways to manage. These guys love to crump with induction and often have significant predictors of difficulty. Knowing that, however, can allow for some careful planning. DSI, awake laryngoscopy with just topicalization (maybe a smidge of sedation/anxiolysis), awake fiberoptic oraltracheal (through a Williams airway) or nasotracheal fiberoptic intubation are all reasonable approaches to the patient you encountered. I would argue that RSI would represent my last choice but would be reasonable if this patient was fixin’ to die and I had no time for other measures. A period of anoxia is definitely suboptimal and in this guy is fairly predictable with RSI and inadequate preoxygenation.

Just for further discussion, I will add that I would not sedate this patient with ketamine. An acute CHF exacerbation is not the time that you want to increase the patient’s systemic vascular resistance. Afterload reduction is the name of the game. Therefore, if I was going to do an awake look, with the goal of keeping the patient breathing, I would use either versed (preferred in my mind) or dexmedetomidine (my pharmacistwould lose their mind but ultimately would be cool.). The downside with dexmedetomidine is that it theoretically may increase SVR. That is why I would probably reach for a little versed to facilitate an awake-look in this patient. I find that etomidate, while it is my favored RSI induction agent, underperforms when used without a relaxant due to the high rate of myoclonus which can be very annoying to overcome especially when it occurs at the worst possible moment.

OP, would you mind discussing why you think the BiPAP failed? And why you chose to perform DL despite having glidescope capabilities? In reading my second question I see that it may sound antagonistic, that is not my goal. I think the discussion is interesting and I am curious what you thought process was during the airway management.

Tough case and thanks for sharing,

iride

Love RSI for the vast majority... The stars are just too high and by definition, everyone is an emergency.
Also second the awake look. I do this often with angioedema, huge whales, those stated above. Nebulous lido and mild sedation.
I will use vitamin K as often as I can I hear ya on the SVR and HR concerns, but I'll take this for a short duration if it buys me an airway. I also have co medicated to mediate this effect often.

Originally Posted by iridesingltrack

I am as perplexed as the others about why you would be "screamed" at by an anesthesiologist about RSI...If it was over this particular case or a similar one I may be able to imagine their point. But, as has been stated, RSI allows for optimization of your first look, which you want to be your best look. In general I am huge fan of RSI and use it regularly. It is clearly the preferred method for dealing with the full stomach as well, and we have to assume that is the vast majority of our patients. Also, full induction doses of sedation in all but maybe dexmedetomidine and ketamine will regularly result in respiratory depression to the point of apnea in the sick patients that we tube, thus negating any advantage to sedation alone. I have even seen someone go apeneic with ketamine, for what it’s worth. Therefore, the general argument against RSI in the ED seems odd. My sense is, and I may be wrong, that this anesthesiologist was either discussing a specific case or is outside the mainstream.

The obese, CHFer with no oxygen reserve are some of the toughest airways to manage. These guys love to crump with induction and often have significant predictors of difficulty. Knowing that, however, can allow for some careful planning. DSI, awake laryngoscopy with just topicalization (maybe a smidge of sedation/anxiolysis), awake fiberoptic oraltracheal (through a Williams airway) or nasotracheal fiberoptic intubation are all reasonable approaches to the patient you encountered. I would argue that RSI would represent my last choice but would be reasonable if this patient was fixin’ to die and I had no time for other measures. A period of anoxia is definitely suboptimal and in this guy is fairly predictable with RSI and inadequate preoxygenation.

Just for further discussion, I will add that I would not sedate this patient with ketamine. An acute CHF exacerbation is not the time that you want to increase the patient’s systemic vascular resistance. Afterload reduction is the name of the game. Therefore, if I was going to do an awake look, with the goal of keeping the patient breathing, I would use either versed (preferred in my mind) or dexmedetomidine (my pharmacistwould lose their mind but ultimately would be cool.). The downside with dexmedetomidine is that it theoretically may increase SVR. That is why I would probably reach for a little versed to facilitate an awake-look in this patient. I find that etomidate, while it is my favored RSI induction agent, underperforms when used without a relaxant due to the high rate of myoclonus which can be very annoying to overcome especially when it occurs at the worst possible moment.

OP, would you mind discussing why you think the BiPAP failed? And why you chose to perform DL despite having glidescope capabilities? In reading my second question I see that it may sound antagonistic, that is not my goal. I think the discussion is interesting and I am curious what you thought process was during the airway management.

Tough case and thanks for sharing,

iride

Thanks for the comments

In this specific case pt was hypoxic in the 80s when he hit the door on ems' bipap but was breathing on his own. I had an attending with me that prefers that we do DL first for the practice rather than jump to glidescope. Pt looked like a disaster and I have to admit, my initial reaction was to RSI with eto/roc because I saw a lengthy sequence. Attending wanted sux. While we prepped pt and attempted to pre02 guy continued to desat but never lost consciousness. He was huge so I upped the dose of meds to what i thought was enough and took a quick look. Obvious difficult airway with tons of secretions. I suctioned and then noticed his sats are in the 60s so i tried to bag him up a bit. This was seemingly more difficult than it should have been. Guy was propped up with an oral airway but had a hairy face and was very large. Eventually his sats come back up to 80s and I opted to DL again. I place tube in esophagus , sats in the garbage. Pull tube out, bag up for another 5 min, redose sux, get a smaller tube (should have done this after first look), and use glidescope. Guys sats never got above 90 with the bag.

As stated above, I don't think it really made a difference with him. My gut tells me that if I had slowed down a little, I could have gotten it the first time. But when I discussed with gas they litterally screamed at me for paralyzing. I have had thus discussion with 5 gas passers and they have all said the same thing, almost no reason to ever paralyze.

Again, I offer this specific case as a single event that I thought not paralyzing pt would have allowed him to breath on his own for a little longer. I really don't think it would have mattered though. The reason I started the thread was less about the case and more about how 5 different anesthesiologists have told me that there is almost no place for paralysis in airway management. The funny thing is that these people still do RSI but seem to be of the opinion that its OK for them in the OR. There argument is always that if you paralyze and can't bag pt then you are in deep $hit, that if you use opiates and benzos you can always just reverse them. I have stated to them that so what if you can reverse them, you still got someone that cant breath. If you go down pathway of intubation in a sick pt, its because they are going to die without it. Cant intubate/ventilate = surgical airway. All of them have scoffed at this idea. Maybe the culture of anesthesiology is a little different here, who knows. Its nice to hear that there is less disagreement than I had imagined from my small sample size.

Originally Posted by danzman

I have had thus discussion with 5 gas passers and they have all said the same thing, almost no reason to ever paralyze.

Ask them what they think about this article published last month that looked at emergent intubations where they found that:

The use of neuromuscular blocking agents was associated with a lower prevalence of hypoxemia (10.1% vs. 17.4%, p = .022) and a lower prevalence of procedure-related complications (3.1% vs. 8.3%, p = .012). This association persisted in a multivariate analysis, which controlled for airway grade, sedation, and institution. Use of neuromuscular blocking agents was associated with significantly improved intubating conditions (laryngeal view, p = .014; number of intubation attempts, p = .049).

My own (inexperienced, perhaps 85 lifetime intubations) opinion on this is that you know the patient needs an airway secured because he is failing to oxygenate on his own. He is failing BiPAP and failing bagging, and therefore you have been essentially forced down a pathway that ends in a secured airway or death.

Given that, there is ample evidence that (1) neuromuscular blockade decreases hypoxemia and increases first-pass intubation success, and (2) that your first look is your best look as the airway is not yet bleeding or traumatized. I think for emergent intubations, not giving a neuromuscular blocking agent compromises your first-pass success and doesn't have much in the way of advantages.

I'd be very interested in what others think of this.

Originally Posted by danzman

Thanks for the comments

Originally Posted by danzman

In this specific case pt was hypoxic in the 80s when he hit the door on ems'bipap but was breathing on his own. I had an attending with me that prefersthat we do DL first for the practice rather than jump to glidescope. Pt lookedlike a disaster and I have to admit, my initial reaction was to RSI witheto/roc because I saw a lengthy sequence. Attending wanted sux. While weprepped pt and attempted to pre02 guy continued to desat but never lostconsciousness. He was huge so I upped the dose of meds to what i thought wasenough and took a quick look. Obvious difficult airway with tons of secretions.I suctioned and then noticed his sats are in the 60s so i tried to bag him up abit. This was seemingly more difficult than it should have been. Guy was proppedup with an oral airway but had a hairy face and was very large. Eventually hissats come back up to 80s and I opted to DL again. I place tube in esophagus ,sats in the garbage. Pull tube out, bag up for another 5 min, redose sux, get asmaller tube (should have done this after first look), and use glidescope. Guyssats never got above 90 with the bag.

As stated above, I don't think it really made a difference with him. My guttells me that if I had slowed down a little, I could have gotten it the firsttime. But when I discussed with gas they litterally screamed at me forparalyzing. I have had thus discussion with 5 gas passers and they have allsaid the same thing, almost no reason to ever paralyze.

Again, I offer this specific case as a single event that I thought notparalyzing pt would have allowed him to breath on his own for a little longer.I really don't think it would have mattered though. The reason I started thethread was less about the case and more about how 5 different anesthesiologistshave told me that there is almost no place for paralysis in airway management.The funny thing is that these people still do RSI but seem to be of the opinionthat its OK for them in the OR. There argument is always that if you paralyzeand can't bag pt then you are in deep $hit, that if you use opiates and benzosyou can always just reverse them. I have stated to them that so what if you canreverse them, you still got someone that cant breath. If you go down pathway ofintubation in a sick pt, its because they are going to die without it. Cantintubate/ventilate = surgical airway. All of them have scoffed at this idea.Maybe the culture of anesthesiology is a little different here, who knows. Itsnice to hear that there is less disagreement than I had imagined from my smallsample size.

Thanks for the reply. I agree that DL is a fundamental skill in EM and I often encourage its use as well but this is probably not the patient to practice on. Not being there it is easy to be critical but I would suggest that if you have VL capability that this is the patient it was designed for, once you have committed yourself to RSI.

Regardless, it sounds like you shed some gastric mucosa over the case, which brings us to anesthesia’s feedback. I can see what they were saying sort of…if they said that this guy should not have been paralyzed then I think that most would agree that ideally this guy is done awake with fiberoptics or toplicalized DL/VL; however, as soon as this patient is dying you must optimize your look (sedation/NMB) and consider prepping the neck simultaneously. This guy must have an airway and sometimes we have to be “all in” in order to secure it. Reversal is meaningless in this case; actually, I can think of no ED intubation where my sedation/paralysis plan involves the idea of reversal. If I am concerned enough to consider reversal then I just do the intubation awake with fiberoptics or topicalized DL/VL with anxiolysis. Regardless, having a detailed, well constructed back up plan is essential.

A simple trick of the trade for better bagging for the junior residents: consider applying surgilube to the facial hair to allow for a better mask seal and I will often use bilateral nasal trumpets with my oral airway. Regardless, it is tough to bag a tremendously obese person due to a heavy chest wall and in the emergent setting is always a two person job; one to secure the mask and one to bag.

iride

Originally Posted by iridesingltrack

Thanks for the reply. I agree that DL is a fundamental skill in EM and I often encourage its use as well but this is probably not the patient to practice on. Not being there it is easy to be critical but I would suggest that if you have VL capability that this is the patient it was designed for, once you have committed yourself to RSI.

Regardless, it sounds like you shed some gastric mucosa over the case, which brings us to anesthesia’s feedback. I can see what they were saying sort of…if they said that this guy should not have been paralyzed then I think that most would agree that ideally this guy is done awake with fiberoptics or toplicalized DL/VL; however, as soon as this patient is dying you must optimize your look (sedation/NMB) and consider prepping the neck simultaneously. This guy must have an airway and sometimes we have to be “all in” in order to secure it. Reversal is meaningless in this case; actually, I can think of no ED intubation where my sedation/paralysis plan involves the idea of reversal. If I am concerned enough to consider reversal then I just do the intubation awake with fiberoptics or topicalized DL/VL with anxiolysis. Regardless, having a detailed, well constructed back up plan is essential.

A simple trick of the trade for better bagging for the junior residents: consider applying surgilube to the facial hair to allow for a better mask seal and I will often use bilateral nasal trumpets with my oral airway. Regardless, it is tough to bag a tremendously obese person due to a heavy chest wall and in the emergent setting is always a two person job; one to secure the mask and one to bag.

iride

Agree. Bagging well is an important airway management skill. Two nasals, an oral, a ramp, two people, and some surgilube all help.

Originally Posted by ActiveDutyMD

Two nasals, an oral, a ramp, two people, and some surgilube all help.

Wait...are we still talking about intubation? Or are we directing porn?

This topic has been discussed many times in the anesthesiology forum:

Succinylcholine in emergent floor intubations

strategy for floor intubations

Floor Intubations, any advice?

Floor intubations

I think it is a misconception that all we deal with in the OR are elective airways where we have all the time in the world to prepare. This is true to some degree but we also deal with a moderate amount of urgent/emergent stuff, both in and out of the OR. Plus we have to go bail out the clowns in the ED every now and then.

Actually, I have only ever seen one or two ED fiascos that we became involved in. The ED guys I work with do a pretty good job of taking care of their own business.

Thought I'd drop in on this thread to weigh in from an anesthesia point of view.

There is a school of thought out there that one ought not to paralyze in these situations. However, I think this is becoming outdated and dogmatic as the evidence mounts that paralysis is best. I think if you've decided to give an induction agent of some kind, you ought to optimize your view and paralyze. I think many of my anesthesia colleagues would agree with me and disagree with the ones at your shop.

The real question in my mind is an awake technique vs. asleep. If presented with your patient and had the few minutes it takes to topicalize, I would probably have done an awake Glidescope. But if the patient is crashing and needs PVC in the trachea nownownow, and you think your intubation attempt will be successful, then paralyze.

As you were.

Originally Posted by Hawaiian Bruin

Thought I'd drop in on this thread to weigh in from an anesthesia point of view.

There is a school of thought out there that one ought not to paralyze in these situations. However, I think this is becoming outdated and dogmatic as the evidence mounts that paralysis is best. I think if you've decided to give an induction agent of some kind, you ought to optimize your view and paralyze. I think many of my anesthesia colleagues would agree with me and disagree with the ones at your shop.

The real question in my mind is an awake technique vs. asleep. If presented with your patient and had the few minutes it takes to topicalize, I would probably have done an awake Glidescope. But if the patient is crashing and needs PVC in the trachea nownownow, and you think your intubation attempt will be successful, then paralyze.

As you were.

What he said. Not paralyzing is probably dogma unless you know that you are not going to be able to secure the airway.

Originally Posted by Hawaiian Bruin

Thought I'd drop in on this thread to weigh in from an anesthesia point of view.

There is a school of thought out there that one ought not to paralyze in these situations. However, I think this is becoming outdated and dogmatic as the evidence mounts that paralysis is best. I think if you've decided to give an induction agent of some kind, you ought to optimize your view and paralyze. I think many of my anesthesia colleagues would agree with me and disagree with the ones at your shop.

The real question in my mind is an awake technique vs. asleep. If presented with your patient and had the few minutes it takes to topicalize, I would probably have done an awake Glidescope. But if the patient is crashing and needs PVC in the trachea nownownow, and you think your intubation attempt will be successful, then paralyze.

As you were.

Ding Ding Ding
We have a winner.

Apologies in advance; I haven't read the rest of the thread, but saw the gist of the topic and wanted to weigh in my n = 1.

Paralyze 'em. I remember thinking as an early second-year resident "this guy doesn't need sedation or paralysis... he's just too obtunded".... then when I got the mac-4 in his throat, I watched the cords snap shut on me and NOT want to open again.

Now, I paralyze everyone.

scroll down on this link and watch the video for a ~20 min debate on this topic (paralytics vs. sedation-only for intubation).

http://emcrit.org/podcasts/paralytic...u-intubations/

What a timely thread!

I am, for the most part, on the wagon for RSI w/ paralytics.

But you have to pick the right situation.

Had a situation 2 nights ago.

Glad I didn't paralyze w/ this very severe angioedema.

Hope she never uses Lisinopril again

As an EM doc you must learn to fear the sedated - hell, induced! - emergent intubation more than the surgical airway.

The decision point is not "NMB or no NMB"...the decision point is "awake intubation vs. RSI"...there are few other options for the traditionally-trained EM doc faced with an emergent airway.

(yes, some of us are very comfortable with DSI and ketamine; but most aren't...yet)

HH