Airway Team Intubations

[Precedex]

Hi I was thinking about my choice of drugs for emergent intubation calls. We are discouraged from using any muscle relaxants unless absolutely necessary, in which case we are supposed to page our attending. Granted different patients call for different choices of medication, but I was wondering how some of the more experienced folks out there approach choice of drugs to facilitate intubation in an emergent setting (excluding true arrests). Please provide your rationale and doses if possible.

Thanks

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[rmh149]

Hi I was thinking about my choice of drugs for emergent intubation calls. We are discouraged from using any muscle relaxants unless absolutely necessary, in which case we are supposed to page our attending. Granted different patients call for different choices of medication, but I was wondering how some of the more experienced folks out there approach choice of drugs to facilitate intubation in an emergent setting (excluding true arrests). Please provide your rationale and doses if possible.

Thanks

Precedex, it is amazing to me when I get called to do an emergency intubation and nobody in the room knows where the Succynlcholine is located. It is my #1 choice NMB for intubation.

Of course, the patient always dictates what meds to use. I usually intubate with Propofol 1.5 to 3mg/kg or etomidate .2 to.4mg/kg (or whatever I think they can tolerate) for induction and Succynlcholine 1.5mg/kg for neuro muscular relaxation. I dont think I have ever used anything other than Succynlcholine as the NMB on an emergency intubation.

Also keep cetecaine spray handy for those that you are absolutely afraid of using a NMB.

Versed would be good, although I dont think it would be convenient to keep that in the intubation box.

 

[IceDoc]

In our code kit, we carry a minimum of:
Propofol
Etomidate
Sux
Rocuronium

Everything else is window dressing. Phenylephrine comes in handy for your induction of dry medicine patients. IV Lidocaine could be used if you do a lot of Neuro ICP issue intubations. You could have epi/atropine available if you feel like it, but these should be on code carts. Glyco if you want an antisialagogue before an awake intubation. The list could go on and on for every conceivable scenario, but like I said it's all window dressing. I just make sure I'm carrying the above 4.

The Roc is only used on patients with a reasonable airway who have a real contraindication to sux (i.e. rapidly climbing or unacceptibly high K+). Last thing I want to do in the 3rd world (aka the floor) is to have an irreversibly paralyzed patient who I can't vent/intub.

Generally the doses are reduced compared to true OR inductions. Many of these patients are hanging by a physiologic thread (otherwise they wouldn't be intubated right?). But you have to actually evaluate the patient and decide how much/little they can tolerate. That ESLD syndrome patient who barely opens his eyes...Etomidate 6mg, Sux 120mg, phenylephrine prn. Let's say he's hepatorenal with a climbing K+ of 7, then Roc 1.2mg/kg. Let's say he's a known or suspected difficult airway, then no paralytic; consider topicalization and brutane.

And always remember, if they're pretty much dead, then just stick the tube in. I watched an ER resident make sure that Etomidate 20mg and Sux 200mg was pushed in a 70 year old who was in respiratory arrest...not much logic in either choice to induce or choice of dose.

 

[rmh149]

In our code kit, we carry a minimum of:

Let's say he's a known or suspected difficult airway, then no paralytic; consider topicalization and brutane.

I will never forget what a wise anesthesiologists said when we went to intubate a large ICU patient in respiratory distress, but still breathing. As the student I was ready to give Etomidate, anectine and intubate her.

Instead we did the right thing, topical spray, versed 2 mg, intubated. It was tough to hit a moving target, but she was still breathing.

His statement "In a situation like this you never want to take away ones ability to save their own life".

 

[Noyac]

I will never forget what a wise anesthesiologists said when we went to intubate a large ICU patient in respiratory distress, but still breathing. As the student I was ready to give Etomidate, anectine and intubate her.

Instead we did the right thing, topical spray, versed 2 mg, intubated. It was tough to hit a moving target, but she was still breathing.

His statement "In a situation like this you never want to take away ones ability to save their own life".

Be careful with the benzocaine spray. We had a case of metHb last week. The nurse put an NGtube in a pt with benzocaine spray used to topicalize the nares.

It only takes a little bit.

 

[rmh149]

Be careful with the benzocaine spray. We had a case of metHb last week. The nurse put an NGtube in a pt with benzocaine spray used to topicalize the nares.

It only takes a little bit.

wow...and we sprayed for at least 7 seconds into a highly vascular area. I wouldnt be surprised if that patient developed metHb. I was under the impression that it took a generous amount.

How was your case treated? O2 and methylene blue? Nasal wash maybe?

 

[TIVA]

If you read the directions on cetacaine spray, you'll find the maximum allowed dosage is 2 sprays at one second each. Not much, is it.

 

[rmh149]

If you read the directions on cetacaine spray, you'll find the maximum allowed dosage is 2 sprays at one second each. Not much, is it.

Not enough to do anything with....

Guess thats why they dont have it anywhere in my hospital....I miss using it as a lubricant for my stylet in my ETT.

 

[jetproppilot]

His statement "In a situation like this you never want to take away ones ability to save their own life".

Thats a powerful statement that I can see how it would have an impact on you.

Keep an open mind, though. There are attendings out there that would differ with that opinion, and I'm one of them.

Once your laryngoscopy skills are so refined that you can intubate a pregnant fire ant, which you should be able to do after five years of a busy practice, succinylcholine in minute doses (20-40mg) provides you with optimum intubating conditions, albeit for a very short time. Which makes it easier on both you and the patient.

And if you fail, which at this point in your career you'll find will be almost never, the sux-redistribution will carry away that very-low-dose CDAZY FAST.. So the patient can still "save their own life."

 

[IceDoc]

Thats a powerful statement that I can see how it would have an impact on you.

Keep an open mind, though. There are attendings out there that would differ with that opinion, and I'm one of them.

Once your laryngoscopy skills are so refined that you can intubate a pregnant fire ant, which you should be able to do after five years of a busy practice, succinylcholine in minute doses (20-40mg) provides you with optimum intubating conditions, albeit for a very short time. Which makes it easier on both you and the patient.

And if you fail, the sux-redistribution will carry away that very-low-dose CDAZY FAST.. So the patient can still "save their own life."

And one of my mentors has the "2 and 2" formula. 2cc Etomidate and 2cc Sux.

 

[rmh149]

This is what is great about this forum. There is always something to learn from ideas from others. Jet and Ice, I will definitely keep those ideas in mind.


I can see it now...the next time I get called down to the ER for intubation...whats going to be going through my head? 2 and 2!