Floor Intubations, any advice?

My advice: never intubate the floor. It rarely works.




J/K.

Wish I could help more.

In these situations, with little known about the patient, I typically only use Brutane.

I must concur. As an ICU man, I routinely use Brutane, and it works well. If Brutane doesn't work, then the patient probably doesn't need intubation.

I do cheat sometimes....50mg of propofol.

militarymd said:

I must concur. As an ICU man, I routinely use Brutane, and it works well. If Brutane doesn't work, then the patient probably doesn't need intubation.

I do cheat sometimes....50mg of propofol.

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Brutane...lmao!

VentdependenT said:

Brutane...lmao!

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laryngophed for hypotension works quite well too....

I think that Ketamine or Etomidate are good to use for hypotensive patients, "Brutane" (nice!) is ok if CODE status is called and there's noone that really can provide a good quick hx for you on the fly. Manufacturers warning to users of "Brutane": may lead to accidental staining of nice new Danskos and patterned Dickie scrubs and favorite cozy scrub jackets with nasty/stinky vomitus if patient is still remotely awake and senses the usage of "Brutane". "Brutane" must be used quickly to take the naughty CODING patient by surprise and be turned off before the defense mechanism of the coding patient (vomitus everywhereus) is activated and all is lost/or just messy for the anesthesiologist! Propofol will make a hypotensive situation even worse, especially if used in recommended doses 1-2.5 mg/kg. Maybe 0.5mg/kg will give you the sedation you might require just to get the tube in without excessive effects on BP, but I like Etomidate or just good 'ole suction / a little "Brutane" / and quick intubation.

We didn't have induction agents where I worked. We used 5-10 mg of valium prior to getting midazolam. Usually when someone is precode, it doesn't take much to knock them down enough. You can RSI them too. They don't become hypotensive if you don't check their BP

Well, as you can tell everyone is different and everyone has their own way of getting the job done. And every patient is also different. If you are intubating because of hemodynamic reasons then less is best. If you are intubating because of neuromuscular reasons, NO SUX, generally. These guys are too weak anyway to need any NMBA's. If you are intubating because the patient is a crack/crystal meth addict and is causing a ruckus, SUX only.

have done too many floor/er/code intubations to count

only ONCE have i used a muscle relaxant and that was rocuronium
only ONCE have i used ketamine...
only ONCE have i used etomidate until I realized that I need to add propofol for it to really kick in

my last few hundred intubations have always been as follows
1) explain to the patient what you are planning to do
2) spray their throat/cords w/ benzocaine
3) give them 2-4mg metoprolol IV
4) give them 25-50mcg fentanyl
5) give them 10-30mg propofol
6) use a Miller 3 (because not only is it impossible for them to suck down their epiglottis against a miller, but also because it really intimidates all the Fleas and Surgeons)
7) put the tube in

and i always have a 10cc stick of 40mcg/cc phenylephrine ready for those poor bastards who have no sympathetic tone left after they loose their need to maintain their work of breathing

joncmarkley said:

Hi, I am a new CA-1. Doing well in the OR with intubating but still need a little help when called for floor intubations, especially awake elective intubations. A little afraid to give to much propofol, whether or not to use ketamine or etomidate for the hypotensive patients, and most importantly whether or not to use muscle relaxants anyone have any advice or know of a good reference ?

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I'm going against the grain on this one. Our chairman discouraged us from using muscle relaxants when I was a resident. I think this is a good approach because you arent as good as you'll be 5-10 years from now.

I havent done a floor intubation in a long time without muscle relaxant. I think it can be done safely, and its a heck of a lot easier.

Very few of the ICU patients I've intubated have had contraindications to sux. Most havent been there long enough to rule out sux because of immobility (guess those people either died or got better and transferred). Most are COPD exacerbations or CHF.

Obviously if youre intubating someone thats almost dead you dont need anything, but I think most people are referring to the intubations where the patient is still aware of whats going on and not ready to check out (yet).

My standard for years has been 2-4 mg midazolam and 40mg sux. If you get in trouble it doesnt last long but gives great (albeit short) conditions for a quick intubation.

Jet,

Welcome back!!!!!

militarymd said:

Jet,

Welcome back!!!!!

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Yeah!

that's pretty funny about the miller 3. i always use it too, just to hear that intern in the corner say "what the hell is that?"

seriously though, it's just a preference thing. as for m. relaxants, most don't, but that shouldn't be set in stone. i kind of agree with what was said above, the better i got, the more often i relaxed (myself and the patient )

brutane... that's hilarious.

militarymd said:

Jet,

Welcome back!!!!!

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You and Venty are gettin me emotional, Mil. I need a tissue.

VentdependenT said:

Yeah!

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Uh, Venty, you're my O-G Showtime Man and all that, but that new Prince avatar looks, uh, well lets just say I liked the other one better.
Find a Prince pic from the earlier (read: cooler) Prince days!

Welcome back J-Boogie!

Listen, regarding the Prince thingy, there was this uprising - I actually felt the need to PM Vent about it...he briefly went form that porn star looking Prince to this macabre skull thing. We begged for the Prince, and we got him back (thankfully). Keep Prince Vent!

dc

jetproppilot said:

Uh, Venty, you're my O-G Showtime Man and all that, but that new Prince avatar looks, uh, well lets just say I liked the other one better.
Find a Prince pic from the earlier (read: cooler) Prince days!

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What? This one isn't gay enough for you?

VentdependenT said:

What? This one isn't gay enough for you?

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I wasnt gonna use that word.

jetproppilot said:

I wasnt gonna use that word.

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I'll kick it old school for your old school ass foo'

VentdependenT said:

I'll kick it old school for your old school ass foo'

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Yeah, Dude, old school Prince!

A U T O MATIC
duh
duh
A U T O MATIC
duh
duh
YOU ASK ME IF I LOVE YOU......


OR


Dig if you will a picture
You and I engaged in a kiss
The sweat of your body covers me
Can you my darling, can you picture
This


like Will Smith said on Bad Boys,

"NOW THATS HOW YOU DRIVE!!!! FROM NOW ON, THATS HOW YOU DRIVE!!!!!

this is just my personal algorithm for floor intubations

1>history - look for contraindication for using thiopental or propofol or
ketamine
thiopental - histamine-release, CI in pxs in anaphylactic shock
propofol - allergy to soya and egg white (albumin)
ketamine - can be used in pxs in hypotensive states
make sure you're able to maintain airway first before you give anything!
and while short history is being taken, have materials prepared: SAL
S-uction
A-irway (ET tube in 3 sizes, just in case you should attempt a blind
nasotrache, mononasals, oral airways, and of course the LMA, stylet
or bougie, bag and mask )
L-aryngoscope (Mac, Mil, McCoy)

2>reason for intubation
a>code - brutane vs lidocaine spray delivers 10mg/spray
b>bronchospasm (asthma vs allergic) - one can do a vagal block for
asthmatic pxs (have never done this before but my
training officer swears by this) or use lidocaine spray
and ketamine for pxs in anaphylactic attacks (px is
assumed to have systemic vasodilation so will become
hypotensive)

3>npo time
a>full-stomach - use Sellick's, for this you need help of another MD.
if in code, suction up to stomach first
b>if in doubt, assume px is in full-stomach

learn to think outside the box:
1-use head rests and shoulder rolls for the obese and anteriorly displaced larynx
2-if anteriorly displaced, (assuming px is already in sniffing position) may use nasotrache with or without use of laryngoscope using right nostril. apply gently and do not proceed if with obstruction (px may have a nasal polyp). you'll hear gush of air with blind nasotrache and misting of ET tube
3-if 3rd attempt or after 10mins still unable to intubate, use LMA. may give a little meds first because awake px may not tolerate it

hope this helps!

why are you all pushing the use of propofol above all? l find it to work to slow for any emergency, while good ol' tio would do just fine in most of situations... not to mention hypotension with usage of propofol

don't get too fancy. but, remember that patients may vomit and aspirate if you just stick in a blade.

brutane may result in injuries to dentition, other airway structures, and psyche. in awake, mentating patients with acceptable airways - it's just plain cruel.

maikmd:
everyone on the floor is assumed to be a full stomach.
also, wtf is a vagal block? you mean anticholinergics?

Intensivist said:

why are you all pushing the use of propofol above all? l find it to work to slow for any emergency, while good ol' tio would do just fine in most of situations... not to mention hypotension with usage of propofol

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What?

when using propofol it takes few minutes and quite a dose to provide a good level of anesthesia, while with tio or etomidate it works quite faster... but nevertheless, l like propofol

Intensivist said:

when using propofol it takes few minutes and quite a dose to provide a good level of anesthesia, while with tio or etomidate it works quite faster... but nevertheless, l like propofol

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Propofol works as fast as either in appropriate doses.

What's tio? Short for thiopental? That can easily cause as much hypotension as propofol.

l've read it, but in realiy, most of hypotension that l've seen, and remember l don't have all that much experience yet, was due to propofol in regular 2mg/kg doses, thiopental is more advised in RSI or am l mistaken, please point out if l am....

In my experience, anesthetic doses of any induction agent, save etomidate, will result in hypotension. But etomidate obviously has other problems (the possibility of adrenocortical suppresion. yes, even after just one dose). Propofol 2mg/kg in a sick, crashing floor patient could be construed as malpractice.

I think I replied somewhere above about the awake, topicalized DL as my plan of choice in most of these people. But I understand it's not for everyone, and the "first look, best look" camp has a valid approach as well.

Intensivist said:

when using propofol it takes few minutes and quite a dose to provide a good level of anesthesia, while with tio or etomidate it works quite faster... but nevertheless, l like propofol

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again, disagree. propofol does not take minutes to work, it takes seconds. it certainly does not take appreciably longer then thiopental or etomidate.
doses of 2mg/kg are used for induction of healthy individuals. Hemodynamically compromised individuals may be induced with slow, judicious use of propofol.

etomidate may also result in hypotension in individuals with limited reserve.

Intensivist said:

l've read it, but in realiy, most of hypotension that l've seen, and remember l don't have all that much experience yet, was due to propofol in regular 2mg/kg doses, thiopental is more advised in RSI or am l mistaken, please point out if l am....

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Propofol 2/kg is going to be way too much in most codes or imminent codes. Those situations are so varied it's not really possible to accurately generalize which agent is "best" and what dose is appropriate. But suffice it to say that I think most of us would agree that

• thiopental doesn't have significant advantages over propofol
• any of (propofol, thiopental, etomidate) can be safely used, +/- concommitant vasopressor support, to induce almost any patient if you know what you're doing and pay attention
• hypotension after induction with etomidate can occur
• adrenal suppression with etomidate really happens, and is something to consider in your risk/benefit decision when choosing an induction agent

My personal preference is to avoid etomidate in most patients, particularly those who are septic and headed toward prolonged ICU stays. A modest dose of propofol chased with a couple hundred mcg of phenylephrine will, in most cases, induce a patient as quickly as etomidate and with reasonable hemodynamic stability. I don't cast stones at ER docs, pulmonologists, surgeons, internists, etc who choose etomidate for its hemodynamic stability - they're not the sorts who have daily experience and a good feel for pushing vasopressor boluses. But you'll find a lot of us in anesthesia prefer the not-etomidate induction.

l wasn't reffering to 2mg/kg propofol dose in code situations but rather comparing begining of anethesia when using different drugs, somehow induction takes longer with propofol and that's why l would avoid it in RSI, no matter the dosage, but if you all say it works just fine l'll give it another shot

Intensivist said:

l wasn't reffering to 2mg/kg propofol dose in code situations but rather comparing begining of anethesia when using different drugs, somehow induction takes longer with propofol and that's why l would avoid it in RSI, no matter the dosage, but if you all say it works just fine l'll give it another shot

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Propofol is the induction agent used in the majority of anesthetics currently, It has almost completely replaced Sodium thiopental in this country.
It does not mean that STP is a bad drug but Propofol has a much better pharmacodynamic and pharmacokinetic profile.
Read about it a little.
On the other hand I do admire your interest in what we do.

Just as I couldn't take it anymore and I started to type a reply, Plankton's post came up. I think his last sentence says it succinctly and with tact so I will just quote it here and move on.

Planktonmd said:

On the other hand I do admire your interest in what we do.

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- pod

well, how do l just dare to debate with you special-know it all-anesthetists.... Americans prise propofol discarding thiopental as a bad never to use drug, but let me remind you that up to today no ideal anesthetic has been invented, therefore you can only choose of certain situation which drug to use. if a patient comes with head trauma and needs a quick induction and intubation, what drug most often you use?

Intensivist said:

well, how do l just dare to debate with you special-know it all-anesthetists.... Americans prise propofol discarding thiopental as a bad never to use drug, but let me remind you that up to today no ideal anesthetic has been invented, therefore you can only choose of certain situation which drug to use. if a patient comes with head trauma and needs a quick induction and intubation, what drug most often you use?

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Your statement about Americans thinking thiopental is a "Bad never to use drug" is simply just not true. There are indications for thiopental and I (and my colleagues) will use it when indicated. But it has no distinct advantage for code/floor situations. I would say that of all induction agents, propofol and thiopental are more alike than any other pair, so I'm not sure why you seem so defensive about using thiopental over propofol. If you like it, so be it. But we all have our reasons for what we use.

Intensivist said:

well, how do l just dare to debate with you special-know it all-anesthetists.... Americans prise propofol discarding thiopental as a bad never to use drug, but let me remind you that up to today no ideal anesthetic has been invented, therefore you can only choose of certain situation which drug to use. if a patient comes with head trauma and needs a quick induction and intubation, what drug most often you use?

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You absolutely can debate with us, and many guys here would be glad to explain things to you but to debate a subject by definition all the participants should be at comparable levels of knowledge of that specific subject.
You my friend do not appear to be an expert on this subject, so it might be more productive if you ask specific questions so people can answer you.

I know where I work thiopental and ketamine are kept locked up; ie it has to be logged like a controlled substance.

Etomidate is in the Pyxsis. So it's usually a Propofol induction.... or a propofol/phenylephrine induction..

totally agree with you that l'm certainly not at level most of you are, and won't be in yrs to come, but nevertheless, l do have some knowledge and would appreciate you all even more if you wouldn't be ignorant to fact that people how aren't anesthetists could know something about anesthesia after all. For the thio question, maybe you should look a bit wider, spread you horizons, because in Europe thio is being used all the time, quite successfully l might add, so once again l wonder how come that after using a forbiden drug people still survive, even more, similar to propofol group. Just maybe l would compare the old one's price with the newer one.....

Intensivist said:

totally agree with you that l'm certainly not at level most of you are, and won't be in yrs to come, but nevertheless, l do have some knowledge and would appreciate you all even more if you wouldn't be ignorant to fact that people how aren't anesthetists could know something about anesthesia after all. For the thio question, maybe you should look a bit wider, spread you horizons, because in Europe thio is being used all the time, quite successfully l might add, so once again l wonder how come that after using a forbiden drug people still survive, even more, similar to propofol group. Just maybe l would compare the old one's price with the newer one.....

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you level of knowledge seems to be very superficial/novice (level of nursing student reading a basic anesthesia text). you are arguing with anesthesia attendings here. people that were using thiopental before you were even in high school.

"know it all anesthetists?" you're right, the anesthesia attendings, fellows, and residents on this forum DO KNOW, as much as anyone in the world, about these particular topics. you are a prime example of how a little knowledge can be very dangerous - you don't even know what you don't know. i would suggest doing nursing, as you already clearly exhibit that mentality.

Intensivist said:

well, how do l just dare to debate with you special-know it all-anesthetists

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Worthwhile "debate" requires two things:
- a baseline level of knowledge comparable to those you are debating
- a willingness to acknowledge that you're wrong

What you're doing isn't "debating" ... it's arguing with people who know more than you do and getting pissy and huffy when they correct you.

Intensivist said:

.... Americans prise propofol discarding thiopental as a bad never to use drug, but let me remind you that up to today no ideal anesthetic has been invented, therefore you can only choose of certain situation which drug to use.

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Thiopental really doesn't offer much of anything that propofol doesn't.

Thiopental is a scheduled drug making its use somewhat inconvenient. It doesn't mix well with several other drugs making its use somewhat more inconvenient.

It used to be a much, much cheaper than propofol. Today, it's not.

It's not that we fat, arrogant, smug, rich, decadent, SUV-driving, warmongering, American capitalist pigs have an anti-thiopental vendetta or secret propofol agenda to push ...

... it's just that for real world, everyday practice, propofol is just a better drug.

If you enlightened Euro types prefer thiopental and chicks with hairy armpits, that's OK.

Intensivist said:

if a patient comes with head trauma and needs a quick induction and intubation, what drug most often you use?

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Propofol.

hahahahaha, dude you are hillarious, never thought a docs ego can be that big.... if you weren't all that behind a EGO of a egomaniac, you would see that what l wrote, and if you found something false you just might quote it and make a point, but you just a guy who doesn't obviously sees more longer that his nose prominent.... Not to mention degrading the nurses... l thought this was suppose to be a educational forum for people to discuss certain matters, not to exhibit rednecks behaviour....
but then again, one sheep doesn't make a herd...

was reffering to jeff....

Jeff05 said:

you level of knowledge seems to be very superficial/novice (level of nursing student reading a basic anesthesia text). you are arguing with anesthesia attendings here. people that were using thiopental before you were even in high school.

"know it all anesthetists?" you're right, the anesthesia attendings, fellows, and residents on this forum DO KNOW, as much as anyone in the world, about these particular topics. you are a prime example of how a little knowledge can be very dangerous - you don't even know what you don't know. i would suggest doing nursing, as you already clearly exhibit that mentality.

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that's actually what we are called over there.

well, then how come docs in Europe do use thio on everyday basis? l'm not trying to be anti-propofol or anything, just was hoping some of great anesthetists, obviously not reffering to jeff, would explain why do they still use it? Not only in cases of outside of OR situations, but in OR as well... And in Europe it is still cheaper, at least in parts that l'm familiar with...

Intensivist said:

well, then how come docs in Europe do use thio on everyday basis? l'm not trying to be anti-propofol or anything, just was hoping some of great anesthetists, obviously not reffering to jeff, would explain why do they still use it? Not only in cases of outside of OR situations, but in OR as well... And in Europe it is still cheaper, at least in parts that l'm familiar with...

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there is nothing wrong with sodium thiopental....I would say that the initial effects are essentially the same as propofol....

however, the SIDE effects of thiopental is the reason why WE don't use it.

Prolonged half life is one reason to not use it.

However, if I had a limited budget....and it cost less....I would use it.

OK,
Thiopental is a great induction agent but there are a few issues that made people shift to Propofol about 15 years ago:
1- Patients have some degree of residual sedation that does not exist with Propofol.
2- There is Histamine release with thiopental that does not happen with Propofol.
3- Propofol is more flexible and easier to titrate to obtain the desired degree of hypnosis or sedation, while with thiopental the transition from light sedation to deep hypnosis and apnea happens very abruptly. This makes Propofol safer.
And your statement about Thiopental being the most common induction agent in Europe is simply false unless you are refering to a specific area in eastern Europe.

Intensivist said:

well, then how come docs in Europe do use thio on everyday basis? l'm not trying to be anti-propofol or anything, just was hoping some of great anesthetists, obviously not reffering to jeff, would explain why do they still use it? Not only in cases of outside of OR situations, but in OR as well... And in Europe it is still cheaper, at least in parts that l'm familiar with...

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Intensivist said:

well, then how come docs in Europe do use thio on everyday basis?

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Ask them.

In the United States
- the cost differential is no longer much of an issue
- it's a scheduled (controlled) drug, so there's more paperwork to use it and it's not always stocked in the rooms

In addition
- it really doesn't do anything better than propofol
- its pharmacokinetics aren't quite as clean as mentioned by others
- you have to reconstitute it
- it'll precipitate if you inadvertently mix it with some other drugs in the IV

You haven't come right out and said you think propofol is inferior to thiopental, but you've implied it (slow onset? suggesting it's not OK for head trauma?) ... it just appears that your thiopental preference stems from misconceptions rather than facts or practical matters.

l never said that l thought thiopental is better then propofol, and after all, l'm just a med student with limited knowledge and experience. l just thought that thiopental was good choice for head trauma since it reduces ICP but not CPP, unlike propofol, please correct me if l'm mistaken. and l didn't say thiopental is more often used in Europe, just said that it is used, not only in rare occasions but on daily basis

Intensivist said:

l never said that l thought thiopental is better then propofol, and after all, l'm just a med student with limited knowledge and experience. l just thought that thiopental was good choice for head trauma since it reduces ICP but not CPP, unlike propofol, please correct me if l'm mistaken. and l didn't say thiopental is more often used in Europe, just said that it is used, not only in rare occasions but on daily basis

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You are actually wrong when you say that STP reduces ICP but not CPP.
STP causes dose dependent drop of BP and as a result it will decrease CPP once the the BP goes under the the threshold for autoregulation.
Why don't you study these 2 drugs a little and then come back and discuss them?