Criteria for intubation

At some point before the surgeon starts the operation.

AmoryBlaine said:

At some point before the surgeon starts the operation.

Click to expand...

Absolutely. I would intubate anytime I felt like the patients breathing may be compromised..anesthesia prior to surgery or clinical evidence of brain injury.

Airway support
Diminished mental status or decreased ability to maintain airway and clear secretions
Compromised airway anatomy
Diminished airway reflexes, full stomach, or fluctuating consciousness
Requirement for sedation where airway control may be difficult to establish
Pharyngeal instability
Pulmonary disease
Acute respiratory distress syndrome
High pressure pulmonary edema unlikely to respond to noninvasive ventilation, or which has not responded to a reasonable trial of noninvasive ventilation
Hypoventilation (including central nervous system causes and weakness)
Hypercapneic respiratory failure that has failed noninvasive ventilation
Failed trial of extubation
Forseeable protracted course of respiratory failure
Circulatory
Cardiopulmonary arrest
Shock

There are alot of criteria for intubating a patient on the internet based on numbers, i.e. PaO2 less than 65 on room air or hypercapnia at a level of PaCO2 > 45 (?), RR greater than . . . There is alot of hesitancy about intubating a patient because of the perceived fear that they will never get off the ventilator. This is not true. A ventilator-dependent pulmonary pathophysiologic disease process i.e. ARDS makes the patient ventilator dependent. The best indication for ventilation is thinking about it (I got this from the new Marino ICU book I believe!). I had a personal experience with intubation, visited my grandmother in the ED, she has chronic hypercarpnia secondary to COPD, was on O2 nasal canulae, looked fine when I saw her, no respiratory distress, pink, normal respiratory rate near 18 (was not giving out from a higher rate) looked calm relaxed, the resident tole them they did a blood gas and that she would discuss with her attending that they would probably ventilate her. I told her that she should treat a patient not a number (apparently she never heard that before). I told my Mom to tell the attending not to intubate her, that she didn't need it. You always need to take any lab results with a grain of salt, and put them into the clinical context. Turns out that the ABG was a venous stick . . . the attending laughed, and said that of course they were not going to intubate her. I really should have used it as a teaching point for the resident, but I was just upset that anyone could be that stupid!


I have similarly walked into a patients room, seen them breathing at a respiratory rate of 45, and immediately told the nurse to page the medical resident or pulmonary fellow because I know for a fact that this patient needs to be intubated, why?, because you can't breath at 50 respirations a minute forever, eventually you fatigue and go into more acute respiratory distress. I actually told the resident who just ordered a CXR, I asked them, "Did you see the patient?" I came back 10, 20 minutes later, and called a respiratory distress code, patient was taken to ICU and was intubated. Bottom-line, take all the evidence together to make a informed decision and always see the patient.

Take a read some about ventilators too, and the definitions of PEEP, peak airway pressure, etc . . . and ventilator mishaps i.e. a patient who was on recently intubated, placed on a ventilator and has sudden onset hypotension, the first adjustment to make on the ventilator will be . . . I highly recommend the ICU book by Marino. ABGs have some value, especially initially, but I think that venous O2 light absorption sensors (NOT in current usage) may help to better define when to intubate a patient in the future. Our ICU just got in some the new pulmonary artery mixed venous oxygen tension sensors, the thinking being that if you know how much oxygen is being extracted out of the blood, and you know arterial oxygenation, you can get a better sense of the need for intubation. . . Here is something to ponder, why does the pulse Ox just measure arterial oxygenation and not also venous oxygenation in a finger? (the answer lies in the "pulse" in pulse ox), and what does pulse ox really measure? It is more related to ventilation that total blood oxygen carrying capacity, which can be influenced by factors such as anemia . . .

Criteria from Basics of Anesthesia
*Provide a patent airway
*Prevent inhalation (aspiration) of gastric contents
*Need for frequent suctioning
*Facilitate positive-pressure ventilation of the lungs
*Operative position other than supine
*Operative site near or involving the upper airway
*Airway maintenance by mask difficult

Green912 said:

Criteria from Basics of Anesthesia
*Provide a patent airway
*Prevent inhalation (aspiration) of gastric contents
*Need for frequent suctioning
*Facilitate positive-pressure ventilation of the lungs
*Operative position other than supine
*Operative site near or involving the upper airway
*Airway maintenance by mask difficult

Click to expand...

What about being super-combative in the trauma bay? That's earned a tube a few times in my experience....not exactly good medicine, but I have to admit that I was happy with the results.......

Usually you have to have a good reason for doing an intubation, (and the accompanying sedation), because residents usually should call their attending, and then make their case for intubation. A patient who is combative in ED may or may not need intubation. Say a patient is intoxication, and broke several ribs and was high risk for falling out of the bed in the ED and getting a pneumothorax or a patient who is at high risk for aspiration, and you want to protect the airway, then you would intubate (which again is not without risks, so you must weight whether the benefits outweigh the risks). Not all/most combative patients in the ED are intubated. Just because a patient is being supercombative doesn't give you the right to sedate and intubate them, which has a risk of ventillator associated pneumoniae if you have trouble weaning them later . . . First, I think you would get a psychiatry consult, then, depending on institution use perphaps "chemical restraints" like IM haldol, and/or ativan. . .

SLUser11 said:

What about being super-combative in the trauma bay? That's earned a tube a few times in my experience....not exactly good medicine, but I have to admit that I was happy with the results.......

Click to expand...

Exactly. The "3 M----- F----- rule"!

ChildNeuro said:

Usually you have to have a good reason for doing an intubation, (and the accompanying sedation), because residents usually should call their attending, and then make their case for intubation. A patient who is combative in ED may or may not need intubation. Say a patient is intoxication, and broke several ribs and was high risk for falling out of the bed in the ED and getting a pneumothorax or a patient who is at high risk for aspiration, and you want to protect the airway, then you would intubate (which again is not without risks, so you must weight whether the benefits outweigh the risks). Not all/most combative patients in the ED are intubated. Just because a patient is being supercombative doesn't give you the right to sedate and intubate them, which has a risk of ventillator associated pneumoniae if you have trouble weaning them later . . . First, I think you would get a psychiatry consult, then, depending on institution use perphaps "chemical restraints" like IM haldol, and/or ativan. . .

Click to expand...

Your response tells me that you haven't spent a lot of time in an adult Trauma Bay.

Patients who are combative in the trauma bay are often drunk or intoxicated with drugs. They may have a concomittant head injury. They are not kept intubated any longer than to sober them up and be cooperative; this is usually just a few hours. The risk of VAP is exceedingly low in this situation. Trauma patients can also be combative due to severe hypoperfusion secondary to fluid losses...a patient this severely injured often warrants intubation regardless of his mental status (or shall we say, in addition to).

There should be no problems weaning an otherwise healthy patient - if there is, its probably because they have a lung contusion or other injury in which case they have probably benefitted from the intubation. Head injured patients with a GCS of 8 or less mandate intubation according to ATLS - this is not done for the convenience of the medical staff.

For patients wih GCS greater than 8, I DO have the right to sedate and intubate the patient in the trauma bay if they are being a danger to themselves and others. I've seen medical personnel be injured by the patients while attempting to take blood or do a physical exam. These patients are often resistant to chemical restraints and without knowing what illegal substances they've taken I'm a bit hesitant to give them benzos, especially in patients with head injuries. I let my anesthesia colleagues do an RSI and decide which meds are best to use for the situation. Trauma patients are assumed to have certain injuries until proven otherwise - its the reason for leaving the C-collar on until the patient is radiographically and sober enough to clinically clear. Protecting the patient from themselves is often the primary goal.

I would NOT generally intubate a drunk patient with a few broken ribs who was sleeping it off in the ED just to protect them from a potential PTX (which after all doesn't necessarily cause respiratory embarassment or need for tube thoracostomy) unless he/she was a danger or had a GCS of 8 or less. Risk of aspiration? Perhaps but a NGT would probably do the patient better if he was able to protect his airway - too drunk to do so? Then yeah, he probably gets to smoke the peace pipe for awhile.

Calling a psych consult? Good idea if its needed (ie, not due to drugs, alcohol or head injury) but in most cases, getting a psychiatry resident down to the Trauma Bay in expedient time would be a miracle. Not a reason to defer the consult obviously, but in most cases the patient isn't combative because of a psychiatric illness but rather self-induced chemically (which will wear off) or because of their traumatic injury (which also doesn't need a psychiatrist).

Traumas in most Level 1 centers are run by senior residents who do not wait for the attending to show up or answer a page before making the decision to intubate. Even if the attending is there, its still the resident's call. If not there, I'm a little too busy to call the attending with the report until everything has settled out. I follow ATLS protocol with a modicum of experience and common sense. I have never had an Anesthesia attending question my request for intubation, either...I suspect in most cases this is true for others in the same postion. We aren't wily-nily intubating people.

oldbearprofessor said:

You guys all have such funny perspectives on this.

I thought the indications were (not an all-inclusive list and oversimplified, this is just for the basic idea....):

- < 26 weeks for prophylactic surfactant
- CDH Dx'd in utero
- NEC/sepsis with significant apnea
- HMD needing surfactant
- low apgars not responsive to bagging

Oh, you weren't talking about neonates?

In that case, I have no idea.

Click to expand...

oldbearprofessor said:

You guys all have such funny perspectives on this.

I thought the indications were (not an all-inclusive list and oversimplified, this is just for the basic idea....):

- < 26 weeks for prophylactic surfactant
- CDH Dx'd in utero
- NEC/sepsis with significant apnea
- HMD needing surfactant
- low apgars not responsive to bagging

Oh, you weren't talking about neonates?

In that case, I have no idea.

Click to expand...

We let the little ones slide on the "3 M-Fer rule" - after all, they're too young to know better!

Kimberli Cox said:

Your response tells me that you haven't spent a lot of time in an adult Trauma Bay.

Patients who are combative in the trauma bay are often drunk or intoxicated with illegal substances. They may have an overlying head injury. They are not kept intubated any longer than to sober them up and be cooperative; this is usually just a few hours. The risk of VAP is exceedingly low in this situation. Trauma patients can also be combative due to severe hypoperfusion secondary to fluid losses...a patient this severely injured often warrants intubation regardless of his mental status (or shall we say, in addition to).

There should be no problems weaning an otherwise healthy patient - if there is, its probably because they have a lung contusion or other injury in which case they have probably benefitted from the intubation. Head injured patients with a GCS of 8 or less mandate intubation according to ATLS - this is not done for the convenience of the medical staff.

For patients wih GCS greater than 8, I DO have the right to sedate and intubate the patient in the trauma bay if they are being a danger to themselves and others. I've seen medical personnel be injured by the patients while attempting to take blood or do a physical exam. These patients are often resistant to chemical restraints and without knowing what illegal substances they've taken I'm a bit hesitant to give them benzos, especially in patients with head injuries. I let my anesthesia colleagues do an RSI and decide which meds are best to use for the situation.

I would NOT generally intubate a drunk patient with a few broken ribs who was sleeping it off in the ED just to protect them from a potential PTX (which after all doesn't necessarily cause respiratory embarassment or need for tube thoracostomy) unless he/she was a danger or had a GCS of 8 or less. Risk of aspiration? Perhaps but a NGT would probably do the patient better if he was able to protect his airway - too drunk to do so? Then yeah, he probably gets to smoke the peace pipe for awhile.

Calling a psych consult? Good idea if its needed (ie, not due to drugs, alcohol or head injury) but in most cases, getting a psychiatry resident down to the Trauma Bay in expedient time would be a miracle. Not a reason to defer the consult obviously, but in most cases the patient isn't combative because of a psychiatric illness but rather self-induced chemically (which will wear off) or because of their traumatic injury (which also doesn't need a psychiatrist).

Traumas in most Level 1 centers are run by senior residents who do not wait for the attending to show up or answer a page before making the decision to intubate. Even if the attending is there, its still the resident's call. If not there, I'm a little too busy to call the attending with the report until everything has settled out. I follow ATLS protocol with a modicum of experience and common sense. I have never had an Anesthesia attending question my request for intubation, either...I suspect in most cases this is true for others in the same postion. We aren't wily-nily intubating people.

Click to expand...

I have spent some time in an adult ED. Yes, many or most of the patients who are combative are under the effects of EtOH or other substances. Perhaps the word "combative" means different things for different people, as I have seen many a combative patients in the ED, most EtOH intoxicated, and they were belligerent and difficult to exam, but we didn't decide to intubate them. Usually we try to talk down the patients, and use chemical restraints. I was just making the point that there are dangers associated with intubation, that it is not an entirely benign procedure, i.e. pneumothorax, etc . . . My example of an EtOH intoxicated patient with broken ribs would be one who is very disoriented and falling out of bed. I have seen alot of very uncooperative EtOH intoxicated patients, that needed alot of coaxing to get them to get the head CT to rule out head trauma etc . . . Maybe because I don't have the experience of you, but I never would have guessed that a patient without respiratory issues would be intubated just because they were being more difficult. Maybe at the institutions where I have done work in the adult ED, they just used different methods. We had a man with alchol withdrawl, positive urine tox for cocaine and marijuana, was very uncooperative, and made people working with him very nervous so they usually entered his room as a team (I followed him post-ED), it took a while to get headMRI, although we had a clear head CT, he even tossed himself out of bed one night. However, we used physical restraints and chemical restraints, at no time did anyone ever advocate intubating him. I understand that trauma patients, i.e. those with severe volume depletion may act irrational, and in their care may need intubation.

***I would be worried about how to justify intubating a non-trauma, non-respiratory distress, belligerent & combative patient for the sole purpose of having a patient that is easier to control, if something went wrong, i.e. pneumothorax, and perhaps cardiopulmonary arrest.**

I would try low-dose haldol or benzos first in a non-trauma, non-respiratory compromised combative patient, monitor their breathing and vital signs closely and intubate then only in the rare case that they needed it. I found this on the internet http://www.mediplane.com/Newsletter/Archives/Summer_2003/summer_2003.html):

Why is it done? RSI has been proven in multiple studies to increase the success rate of intubation and to decrease associated complications of intubation when compared to intubations performed without facilitation. It may also be used as a last resort with combative patients posing a threat to themselves or their healthcare provider when all other means of restraint have failed.

Who Receives the RSI Procedure? Indications for endotracheal intubation with RSI are similar to those of endotracheal intubation without RSI. The difference is that the patient may be earlier in their clinical course. Indications for performing RSI intubation are:

Any patient with:
• decreased respiratory drive or inefficient respiratory effort
• partially obstructed airway
• inability to maintain airway
• closed head injury
• decreased level of consciousness leading to lack of protective airway and reflexes.
• combative patients when all another measures have failed

It would be helpful if someone could give a case scenario of a patient who needed RSI, we see so many combative patients . . .

If two interns look at eachother and ask "should we intubate?", then the patient should already have been intubated.

If two residents look at eachother and ask "should we intubate?", then the intern should already have intubated.

Thats what I was taught on my Anesthesia rotation.

Kimberli Cox said:

Your response tells me that you haven't spent a lot of time in an adult Trauma Bay.

Patients who are combative in the trauma bay are often drunk or intoxicated with illegal substances. They may have an overlying head injury. They are not kept intubated any longer than to sober them up and be cooperative; this is usually just a few hours. The risk of VAP is exceedingly low in this situation. We aren't wily-nily intubating people.

Click to expand...

I know that VAP usually occurs after a couple of days on the vent, however, it can occur at anytime, see reference below, and patients who are EtOH intoxicated are a setup for aspiration pneumoniae anyhow. It would be interesting to see a study on the outcome of ventillated EtOH withdrawl patients who are ventillated, versus those who are not, but I would guess it is used to rarely that it would be hard to study.

VAP occurs in up to 25% of all people who require mechanical ventilation. VAP can develop at any time during ventilation, but occurs more often in the first few days after intubation. This is because the intubation process itself contributes to the development of VAP. VAP occurring early after intubation typically involves fewer resistant organisms and is thus associated with a more favorable outcome.

If a combative EtOH withdrawl patient presents, and you have labs showing no other drugs on board, wouldn't it be first line to give benzos? Isn't this a good idea if the history is bad and the patient may have DTs?

ChildNeuro said:

and patients who are EtOH intoxicated are a setup for aspiration pneumoniae anyhow. It would be interesting to see a study on the outcome of ventillated EtOH withdrawl patients who are ventillated, versus those who are not, but I would guess it is used to rarely that it would be hard to study.

Click to expand...

How would being a "setup for aspiration pneumonia" make you less likely to intubate? Maybe I don't completely understand what you mean, but I would think that aspirating/having possible airway compromise would earn you a tube faster. Besides establishing a protected airway, it would allow you to bronch/possibly evacuate some of that aspirate.

Also, the comment about benzos and withdrawal is kind of odd. Sure, once the patient has been assessed and treated, you would give low-dose benzos for withdrawal, but that wouldn't factor into my decision on what to give the acutely traumatized patient in the trauma bay.

Trust me, plenty of trauma patients receive "chemical restraints," or Vitamin H as I like to call it. I personally start out with 5 of haldol and 2 of versed. There are still plenty of situations where intubation is justified, however, and often the chemical restraints rob the patient's respiratory drive and lead to a tube. Nobody gets intubated without getting benzos first. I think that would be very difficult to perform on a fully awake patient.

SLUser11 said:

How would being a "setup for aspiration pneumonia" make you less likely to intubate? Maybe I don't completely understand what you mean, but I would think that aspirating/having possible airway compromise would earn you a tube faster. Besides establishing a protected airway, it would allow you to bronch/possibly evacuate some of that aspirate.

Also, the comment about benzos and withdrawal is kind of odd. Sure, once the patient has been assessed and treated, you would give low-dose benzos for withdrawal, but that wouldn't factor into my decision on what to give the acutely traumatized patient in the trauma bay.

Trust me, plenty of trauma patients receive "chemical restraints," or Vitamin H as I like to call it. I personally start out with 5 of haldol and 2 of versed. There are still plenty of situations where intubation is justified, however, and often the chemical restraints rob the patient's respiratory drive and lead to a tube. Nobody gets intubated without getting benzos first. I think that would be very difficult to perform on a fully awake patient.

Click to expand...

OK, here is my reasoning, please see article posted below, the aspiration pneumoniae in alcoholism is *multifactorial* and may be silent, i.e. an alcoholic patient who is aspirating a small amount, maybe secondary to decreased cough reflex may be doing so in front of your eyes, also the immune system is impaired, so just by intubating the patient, which in a normal patient may only cause a slight increase in aspiration pneumoniae, I postulate that such a maneuver might significantly increase the risk of aspiration pneumoniae in an alcoholic. See below:

Alcohol, Immunosuppression, and the Lung
Kyle I. Happel and Steve Nelson

Section of Pulmonary and Critical Care Medicine, Alcohol Research Center, Louisiana State University Health Sciences Center, New Orleans, Louisiana

Correspondence and requests for reprints should be addressed to Steve Nelson, M.D., 1901 Perdido Street, Suite 3205, New Orleans, LA 70112. E-mail: [email protected]

ABSTRACT

Bacterial pneumonia is the most common cause of lower respiratory tract infection in immunocompromised populations, including the alcohol-abusing patient. Furthermore, alcoholics are frequently infected with highly virulent respiratory pathogens and consequently experience increased morbidity and mortality from bacterial pneumonia. The resulting increase in health care resource use in these patients represents a significant public health concern. Host defense mechanisms are operant from the nasopharynx to the alveolus, many of which are adversely affected by excessive alcohol intake. Although the increased risk of oropharyngeal aspiration has been recognized for centuries, only recently have detailed studies of the mechanical, innate, and adaptive immune systems identified specific mechanisms throughout the aerodigestive tract whereby ethanol exposure renders the individual more susceptible to infection. In addition to directly inhibiting the ability of resident lung immune cells to kill bacteria, excessive ethanol use suppresses the normally protective acute inflammatory response to infection, resulting in the defective recruitment of additional innate immune cells. Additionally, ethanol disrupts the intricate interface that exists between innate and adaptive pulmonary immunity, further hindering the alcoholic host's ability efficiently to eliminate invading pathogens. Whether immunomodulatory therapies, designed to augment the immune response in such patients, will be effective adjunct therapy in such patients remains to be determined. This article reviews some of the key mechanisms of pulmonary host defense that are negatively impacted in the setting of alcohol abuse.

Obvious cases of a setup for aspiration need intubation, but most alcoholics, however are not at risk for aspiration pneumoniae for *years* are obviously not intubated for years . . . I am postulating that intubating an alcoholic patient with alreay depressed immune system may introduce bacteria that are not cleared, and if done for only a couple of hours will obviously not decrease the risk of aspiration in a normal appearing alcoholic patient.

ChildNeuro said:

Not all/most combative patients in the ED are intubated. Just because a patient is being supercombative doesn't give you the right to sedate and intubate them, which has a risk of ventillator associated pneumoniae if you have trouble weaning them later . . . First, I think you would get a psychiatry consult, then, depending on institution use perphaps "chemical restraints" like IM haldol, and/or ativan. . .

Click to expand...

Dangerous dangerous.

I've intubated many a combative patient, especially in a trauma setting. Think about it this way. Someone has lots of ETOH on board. They also have a C2 or C3 fracture (which is undiagnosed at this point). They come in, collared, in the trauma bay, and are writhing around because they are high/drunk. You NEED to sedate them and intubate them to protect them. Its a very ugly sight when the patient piths themselves in front of you.

Q

Of course a trauma situation is different where you might suspect cervical fx, then I would see you would need to intubate a patient who is in danger of pithing themselves. I think that even at most of the Level 1 trauma centers, there are alot of intoxicated/combative patients who do not have suspected head trauma, i.e. I have seen many who by history/physical examination have not gotten three-way cervical x-rays or head/spine CT at a level 1 trauma center. I think that what I originally protested was a blanket statement saying that combative patients in ED can be intubated just because they are combative. I have seen many many beligerent/combative EtOH intoxicated patients walking around a trauma cursing, i.e. being combative, but no hx of head trauma per patient, no hx of trauma, no cervical tenerness, etc . . . a head CT would often be done to rule a bleed causing symptoms, but if after thorough history and exam there is no reason to suspect a cervical neck fx then imaging studies aren't done, nobody runs in and yells that this man should be intubated because we have to rule out a cervical neck fracture. Obviously is a patient is collared coming in then you need to maintain in-line cervical stability by any means possible. . . again as I distill my statement:

***I would be worried about how to justify intubating a non-trauma, non-respiratory distress, belligerent & combative patient for the sole purpose of having a patient that is easier to control, if something went wrong, i.e. pneumothorax, and perhaps cardiopulmonary arrest.**

ChildNeuro said:

***I would be worried about how to justify intubating a non-trauma, non-respiratory distress, belligerent & combative patient for the sole purpose of having a patient that is easier to control, if something went wrong, i.e. pneumothorax, and perhaps cardiopulmonary arrest.**

Click to expand...

After all my years, I've never had a ventilator caused pneumothorax, nor a cardiopulmonary arrest.

As for VAP, I've generally only seen it in long term SICU or MICU players, and they are generally moribund secondary to their primary dysfunction anyways.

Healthy people generally should be able to handle an intubation without difficulty. Otherwise, outpatient surgeries wouldn't be where they are today!

Q

ChildNeuro said:

I postulate that such a maneuver might significantly increase the risk of aspiration pneumoniae in an alcoholic.

I am postulating that intubating an alcoholic patient with alreay depressed immune system may introduce bacteria that are not cleared, and if done for only a couple of hours will obviously not decrease the risk of aspiration in a normal appearing alcoholic patient.

Click to expand...

I don't think that the OP was asking for hypotheses or study proposals.

ChildNeuro said:

Of course a trauma situation is different where you might suspect cervical fx, then I would see you would need to intubate a patient who is in danger of pithing themselves.

I think that what I originally protested was a blanket statement saying that combative patients in ED can be intubated just because they are combative. I have seen many many beligerent/combative EtOH intoxicated patients walking around a trauma cursing, i.e. being combative, but no hx of head trauma per patient, no hx of trauma, no cervical tenerness, etc . . . a head CT would often be done to rule a bleed causing symptoms, but if after thorough history and exam there is no reason to suspect a cervical neck fx then imaging studies aren't done, nobody runs in and yells that this man should be intubated because we have to rule out a cervical neck fracture. Obviously is a patient is collared coming in then you need to maintain in-line cervical stability by any means possible. . . again as I distill my statement:

***I would be worried about how to justify intubating a non-trauma, non-respiratory distress, belligerent & combative patient for the sole purpose of having a patient that is easier to control, if something went wrong, i.e. pneumothorax, and perhaps cardiopulmonary arrest.**

Click to expand...

I like how you keep reducing the severity of the patient to better justify your argument. Pretty soon it's going to be a sober guy who drank some cough syrup.


The more you try to justify your statement with "facts," the more you show that you don't know what you're talking about. I swear I'm going to cry if you draw one more "gee whiz" correlation along the lines of "benzos will settle him down, and treat possible alcohol withdrawal. YAY!"

As for the "blanket statement," re-read it. "What about being super-combative in the trauma bay?" Tell me how that applies to the healthy, non-trauma ER patient who had a glass of wine with dinner that you are so valiantly protecting.

None of us here are experts on this subject. But, you are basically acting like a know-it-all that really doesn't know s#@t, and your false self-righteousness is really bugging me.

Nevermind. I'm just going to blindly agree with you so you'll quit posting on the subject.

SLUser11 said:

What about being super-combative in the trauma bay? That's earned a tube a few times in my experience....not exactly good medicine, but I have to admit that I was happy with the results.......

Click to expand...

Well, I certainly didn't want to be a know-it-all, I just didn't want people to get the wrong idea about intubation/sedation, the first goal of physicians is to do no harm. You by your own words seem to admit that intubating a patient who is being super-combative in the trauma bay is "not exactly good medicine, but I have to admit that I was happy with the results . . . ."

It appeared to me that you were indicating that intubating this patient was "not good medicine", which in my mind implies that anything medically critical has been ruled out. This really surprised me that a hospital would intubate a patient when it is not considered "good medicine" but just to be "happy with the results."

What could have been a reasonable talk about an important talk appears to have degenerated, I apologize if I am somehow responsible for that. I do think it is important to discuss rare complications of procedures especially when they may not be medically indicated. Most children with a viral illness like chickenpox who are given aspirin don't get Reyes syndrome, but we recommend against it and it has reduced dramatically a rare disease. Sometimes you have to do a careful evaluation and a certain management decision thousands of times to save the life of one patient over the course of a medical career, but in the end it is worth it.

How would you feel if you mother was intubated in the ED and that the intern thought that it was "not good medicine" but were "happy with the results."

You don't need to agree with me, but I wanted to clarify my position.

ChildNeuro said:

Well, I certainly didn't want to be a know-it-all, I just didn't want people to get the wrong idea about intubation/sedation, the first goal of physicians is to do no harm. You by your own words seem to admit that intubating a patient who is being super-combative in the trauma bay is "not exactly good medicine, but I have to admit that I was happy with the results . . . ."

It appeared to me that you were indicating that intubating this patient was "not good medicine", which in my mind implies that anything medically critical has been ruled out. This really surprised me that a hospital would intubate a patient when it is not considered "good medicine" but just to be "happy with the results."

What could have been a reasonable talk about an important talk appears to have degenerated, I apologize if I am somehow responsible for that. I do think it is important to discuss rare complications of procedures especially when they may not be medically indicated. Most children with a viral illness like chickenpox who are given aspirin don't get Reyes syndrome, but we recommend against it and it has reduced dramatically a rare disease. Sometimes you have to do a careful evaluation and a certain management decision thousands of times to save the life of one patient over the course of a medical career, but in the end it is worth it.

How would you feel if you mother was intubated in the ED and that the intern thought that it was "not good medicine" but were "happy with the results."

You don't need to agree with me, but I wanted to clarify my position.

Click to expand...

(not responding because I want you to STFU and I know you'll have to reply to whatever I say)

To the OP:


the reason it is confusing is because there is no clear cut awnser to this question.

There are all the obvious reasons. The one caveat is to never intubate someone based on a lab value. Emergent intubations are made based on clinical presentation. If you wait on lab values, or determine it by lab values, you will NOT intubate someone who needed it. You will INTUBATE someone who was breathing fine but has an odd lab.

I am going to pass on the trauma thing because until you have been there, its hard to explain.