ACLS intubation medications

[anbuitachi]

our usual practice here at my institution is when we are called to tube in a code, we tube w/o giving any medication cause the idea is an arrested patient is relaxed and out of it. However recently I noticed a couple ppl trained elsewhere giving succinylcholine in a code prior to intubation. What do you do at your place of practice? Do you give succinylcholine in case the CPR and ventilation is so good that the muscle is not relaxed??

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[Ronin786]

I wouldn't give succinylcholine, especially given the possibility of hyperkalemic arrests.

If I'm having trouble getting the mouth open, you can't beat a stick of roc for keeping your hemodynamics stable.

 

[AdmiralChz]

Oy, this reminds me of back in my old EMS days when a patient reached up at the paramedic intubating during a code. I had just walked in and CPR has been in progress for 5 minutes...

 

[MirrorTodd]

Oy, this reminds me of back in my old EMS days when a patient reached up at the paramedic intubating during a code. I had just walked in and CPR has been in progress for 5 minutes...

That probably speaks in favor of not giving any drugs. Could you imagine waking up after cadiac arrest to someone forcing your jaw open and trying to shove a tube down your trachea, but being unable to do anything about it because of the paralytics?

 

[Shimmy8]

Walked in on a code once during residency where they got ROSC and patient "woke up" while the blade was in his mouth and Intensivist DL/intubating. Bit down so hard knocked two front teeth sideways.

No paralytic for me.

 

[OB1🤙]

Brutane in codes.

If you need paralytic, they're probably not really coding.

 

[Soccer171983]

You shouldn't be needing to paralyze in a code situation especially given that code could be from electrolyte abnormalities especially in a renal patient (hyperkalemia and succh a big no no). They generally, if coding, wont have a pressure and the biggest concern is getting o2 in them and most meds pushed during RSI could have adverse outcomes with this kind of a patient. I recommend dropping in the tube as quick as possible and if somehow they truly aren't coding then can proceed with the RSI pathway (versed/etomidate, versed/succh if labs known). IF they bite the tube or start moving all the better !

 

[anbuitachi]

You shouldn't be needing to paralyze in a code situation especially given that code could be from electrolyte abnormalities especially in a renal patient (hyperkalemia and succh a big no no). They generally, if coding, wont have a pressure and the biggest concern is getting o2 in them and most meds pushed during RSI could have adverse outcomes with this kind of a patient. I recommend dropping in the tube as quick as possible and if somehow they truly aren't coding then can proceed with the RSI pathway (versed/etomidate, versed/succh if labs known). IF they bite the tube or start moving all the better !

so 100mg of roc or so sounds good. but dont they usually say if the patient is moving thats often a sign of good CPR, not necessarily the patient is back

 

[pgg]

I usually favor paralytic because if I'm there to put in a tube, the patient is getting a tube, and there's no point in making it harder than it has to be.

Paralysis makes intubating easier. Paralysis makes mask ventilation easier. I try to make a habit of doing things that make my life easier.

 

[psychbender]

If they're truly a code, they're relaxed, and I give nothing. If it's a respiratory failure, pt obtunded but not dead, I may still give nothing, or some token sedation with roc, if my gestalt is that I'll need it.

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[hankbb02]

Paralytic to ensure your first attempt is the best attempt. You can always apologize later if they recall anything. This is a circumstance where my number 1 priority of keeping the patient safe supersedes my number 2 priority of keeping them comfortable.

 

[deleted162650]

I usually favor paralytic because if I'm there to put in a tube, the patient is getting a tube, and there's no point in making it harder than it has to be.

Paralysis makes intubating easier. Paralysis makes mask ventilation easier. I try to make a habit of doing things that make my life easier.

So how long are you waiting after you push your paralytic, 'cuz something tells me that circulation time in the setting of CPR isn't quite normal, and that "60 seconds" for intubating conditions is more like 5+ minutes when some "high quality chest compressions" are the only thing pushing your drugs around. Maybe you could overcome that by pushing like 5-10x the normal dose, but I don't think that's what people are doing. If CPR is in progress, the patient is flaccid and nothing is needed, and I don't think your drugs are helping you out at all 'cuz they're still sitting just past the tip of whatever cannula you injected them through by the time blade meets vallecula.

 

[pgg]

So how long are you waiting after you push your paralytic, 'cuz something tells me that circulation time in the setting of CPR isn't quite normal, and that "60 seconds" for intubating conditions is more like 5+ minutes when some "high quality chest compressions" are the only thing pushing your drugs around. Maybe you could overcome that by pushing like 5-10x the normal dose, but I don't think that's what people are doing. If CPR is in progress, the patient is flaccid and nothing is needed, and I don't think your drugs are helping you out at all 'cuz they're still sitting just past the tip of whatever cannula you injected them through by the time blade meets vallecula.

I agree, if the patient is pulseless, they don't need induction agent or paralytics, and even if you gave them, they wouldn't go anywhere.

But I'd bet 90% of the "codes" I respond to in the hospital are some flavor of respiratory failure or GCS <8, not pulseless people though.


ETA - Just reread the OP, which specifically mentioned an "arrested" patient. That's what I get for poor reading comprehension.

 

[fakin' the funk]

1) Please do not ever push 100mg rocuronium at a code. FFS.

2) Codes aren't black and white. There are "codes" where the patient is literally "Hey get off my chest!" to those codes where the good compressions get enough of a perfusion pressure that the patient wakes up / coughs / reaches up, only to then become comatose again during compressor breaks, to $hitty codes with truly pulseless dead-ass people or crappy compressions. How and why you do endotracheal intubation depends on a lot of factors. And unfortunately, a lot of that info may not be available in a loud/chaotic environment. My advice would be to use the minimum amount of muscle relaxant to achieve intubation safely and quickly when indicated. This might be as little as 0.1-0.2mg/kg rocuronium. I do agree that staying away from succinylcholine at codes is generally a good idea.

 

[fakin' the funk]

I usually favor paralytic because if I'm there to put in a tube, the patient is getting a tube, and there's no point in making it harder than it has to be.

Paralysis makes intubating easier. Paralysis makes mask ventilation easier. I try to make a habit of doing things that make my life easier.

Do the intensivists evaluating the neurological status of the patient favor your use of neuromuscular blockade?

 

[deleted59964]

1) Please do not ever push 100mg rocuronium at a code. FFS.

Why not?

2) ... My advice would be to use the minimum amount of muscle relaxant to achieve intubation safely and quickly when indicated. This might be as little as 0.1-0.2mg/kg rocuronium.

Why the low dose roc?

and

Do the intensivists evaluating the neurological status of the patient favor your use of neuromuscular blockade?

huh, what's the concern here?

 

[WheezyBaby]

Why the low dose roc?

and

Do the intensivists evaluating the neurological status of the patient favor your use of neuromuscular blockade?

huh, what's the concern here?

I'm assuming he means for postarrest cooling eval

 

[deleted59964]

If only there was a drug that reversed neuromuscular blockade

 

[fakin' the funk]

Why the low dose roc?

and

Do the intensivists evaluating the neurological status of the patient favor your use of neuromuscular blockade?

huh, what's the concern here?

1) 100mg rocuronium is unnecessary to facilitate laryngoscopy in a moribund patient, and could easily last 2+ hours. Neuro exam as early as possible after ROSC (i.e., immediately) is paramount.
2) I am aware of sugammadex; thank you for your ignorance and condescension. Is your intensivist aware of sugammadex and its dosing? Is sugammadex on the code cart? Are you giving it personally? Are you giving recommendations to the primary physician as to when to give it? Is sugammadex necessary when the neuromuscular blockade wasn't necessary in the first place?

 

[anbuitachi]

1) 100mg rocuronium is unnecessary to facilitate laryngoscopy in a moribund patient, and could easily last 2+ hours. Neuro exam as early as possible after ROSC (i.e., immediately) is paramount.
2) I am aware of sugammadex; thank you for your ignorance and condescension. Is your intensivist aware of sugammadex and its dosing? Is sugammadex on the code cart? Are you giving it personally? Are you giving recommendations to the primary physician as to when to give it? Is sugammadex necessary when the neuromuscular blockade wasn't necessary in the first place?

How long are you waiting after pushing 20 of roc before intubating

 

[fakin' the funk]

How long are you waiting after pushing 20 of roc before intubating

It depends. Y'all are the ones trying to give neuromuscular blockers at codes, not me.

 

[pgg]

It depends. Y'all are the ones trying to give neuromuscular blockers at codes, not me.

Not all codes are created equal.

98% of the "codes" I respond to aren't CPR-in-progress, they're just respiratory failure or the like. No one's getting angsty about immediate neuro checks in these people once they're riding the vent.

 

[deleted59964]

1) 100mg rocuronium is unnecessary to facilitate laryngoscopy in a moribund patient, and could easily last 2+ hours. Neuro exam as early as possible after ROSC (i.e., immediately) is paramount.
2) I am aware of sugammadex; thank you for your ignorance and condescension. Is your intensivist aware of sugammadex and its dosing? Is sugammadex on the code cart? Are you giving it personally? Are you giving recommendations to the primary physician as to when to give it? Is sugammadex necessary when the neuromuscular blockade wasn't necessary in the first place?

Ok - first up, agree nmba's are unnecessary in many codes. If you're tolerating cpr there is little to be gained by adding a muscle relaxant. My practice with nmba's and codes has not been discussed so far, so don't make the leap to asssuming what I do.

But you said ... do not ever push 100mg of roc at a code, then suggested a low dose of roc, then made a comment about post arrest evaluation of neurological status.

So I called you on it.

100mg of roc allows rapid establishment of favourable intubating conditions in codes for respiratory failure and other situations where the patient still has some tone and may have a contraindication to sux... codes are not all the same and so I disagree that 100mg of roc is always a poor choice.

A small dose of roc as you suggest is a long way from accepted practice - I can see no logical reason for it... that is not good advice for junior trainees ( or anyone else)

Sugammadex is of course an option to reverse roc if need be, as is neostigmine in certain circumstances. The intensivists I work with know all about it ... but really post arrest neurological assessment can wait for even 100mg of roc to wear off. In fact never once have I reversed a paralysed patient who coded - but if that's what you're worried about ... well then just reverse. But I would Just treat the patient as though they may have a good neurological outcome until the roc wears off.

I'm genuinely surprised at your stance, and particularly your advice to give low dose roc in a code. Apologies if you're offended - but I stand by my argument.

 

[nimbus]

I agree with JobsFan. If you are going to use NMB for whatever reason during a code, don't dick around with a small dose. I can't understand the logic behind that. If you don't need it, don't use it. If you do need it, use a real dose that's guaranteed to work.

 

[fakin' the funk]

I agree with JobsFan. If you are going to use NMB for whatever reason during a code, don't dick around with a small dose. I can't understand the logic behind that. If you don't need it, don't use it. If you do need it, use a real dose that's guaranteed to work.

So the consensus is, zero mg or 100mg. Reasonable.

 

[nimbus]

So the consensus is, zero mg or 100mg. Reasonable.

It seems more reasonable than the 0.1-0.2 mg/kg dose you suggested in your previous post. Do you actually give people 10mg of roc in real life situations? Or are you just being argumentative? Does it work? Sincere question. I've never tried it.

If I'm responding to a code or urgent intubation and I thought NMB would be helpful I would give 50-100mg. I certainly wouldn't be giving 5, 10, 15, or 20mg.

 

[vector2]

I give NMB to at least 50-60% of floor patients and almost 100% of my ICU patients in which I know their AM K and the length of their downtime. I've had a ton of patients getting high quality cpr whose jaws were still locked, and I don't know where this notion that unconscious and tolerating cpr = optimal intubating/ventilating conditions came from.

On a related note, this study has been making the rounds for awhile. Granted, it's retrospective, but I think it lends credence to the hypothesis that interrupting high quality cpr is what kills, not failure to get the tube in Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival