Another airway case

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TimesNewRoman said:
Do it all the time. Works really well if the patient is cooperative. We usually do it to drain PTAs. Do it similar to an awake FOI after nebs +/- topical. When patients hold the VL, they can go a lot deeper than you’d think. I’ve also done it on patients with trismus. It’s gives you a free look to know “ok, chip shot, fine to go.”
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No way nebs and topical work in this pt.
 
freedeshaun2021 said:
Interesting-- I wouldn't have thought that the nebs/topical lidocaine would work if there was blood in the field.

Some of my co-residents suggested doing a VL with him sitting up and holding the blade upside down-- I may have been able to do that and used the fiber as a driveable stylet.
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Holding the blade upside down? I cannot compute that without thinking it's digging into the roof of the mouth. Please explain.
 
freedeshaun2021 said:
Interesting-- I wouldn't have thought that the nebs/topical lidocaine would work if there was blood in the field.

Some of my co-residents suggested doing a VL with him sitting up and holding the blade upside down-- I may have been able to do that and used the fiber as a driveable stylet.
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Yea. That’s what I mean. This is the technique we use with some frequency for draining PTAs.
 
Arch Guillotti said:
No way nebs and topical work in this pt.
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Fair. You don’t really need much of anything though to do what I’m describing. If the patient holds the blade sitting up and you see everything looks good with the FOI, I’d push drugs and ram it through rapidly.
 
freedeshaun2021 said:
Interesting-- I wouldn't have thought that the nebs/topical lidocaine would work if there was blood in the field.
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It won't work well. That's why glyco is your friend with topical anesthesia. Nor will tye presence of crusty old blood allow lidocaine to anesthetize the underlying mucosa.
 
chessknt said:
And how would you discern anxiety/pain from progressing hemorrhagic shock in this case?
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I'm going to give you the benefit of the doubt that you're not just being argumentative in this case

Not only is tachycardia a non-specific sign, even in the classical trauma teaching it's one of the later signs of hemmorhagic shock. I'd expect it to be coupled with altered mental status, hypoxia from poor V/Q mismatch, significantly low BP (think systolic in the 60s and 70s). Cool and clammy is one of the best and most underrated signs out there. When you see enough of these traumas you get the feel between the one who's getting ready to crump and the one that is just recovering from the literal shock of what just happened. The GSW that can't swear at you is the one you worry about. This kid obviously tolerated an AFOI while leaning forward and following instructions. He's far away from crumping.

Also this may be just my opinion, but while people can die from stupid induction doses, it's much more often poor resuscitation and a lack of vasopressor that does them in. Induce with whatever agent you want, but if you put a guy on PPV who's absolutely depleted without a pressor and fluids nearby they're going to code. It's not the white stuff that kills them, it's the lack of purple.
 
Ronin786 said:
I'm going to give you the benefit of the doubt that you're not just being argumentative in this case

Not only is tachycardia a non-specific sign, even in the classical trauma teaching it's one of the later signs of hemmorhagic shock. I'd expect it to be coupled with altered mental status, hypoxia from poor V/Q mismatch, significantly low BP (think systolic in the 60s and 70s). Cool and clammy is one of the best and most underrated signs out there. When you see enough of these traumas you get the feel between the one who's getting ready to crump and the one that is just recovering from the literal shock of what just happened. The GSW that can't swear at you is the one you worry about. This kid obviously tolerated an AFOI while leaning forward and following instructions. He's far away from crumping.

Also this may be just my opinion, but while people can die from stupid induction doses, it's much more often poor resuscitation and a lack of vasopressor that does them in. Induce with whatever agent you want, but if you put a guy on PPV who's absolutely depleted without a pressor and fluids nearby they're going to code. It's not the white stuff that kills them, it's the lack of purple.
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I don't think of a young guy who's hemorrhaged to a heart rate of 120 as typically being significantly altered or hypotensive. The "classical teaching" tables I'm familiar with wouldn't typically either. Don't have a boatload of experience here though. Agree with your latter point
 
WheezyBaby said:
I don't think of a young guy who's hemorrhaged to a heart rate of 120 as typically being significantly altered or hypotensive. The "classical teaching" tables I'm familiar with wouldn't typically either. Don't have a boatload of experience here though. Agree with your latter point
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1613934761964.png
 
nimbus said:
The risk is that it may stir up more bleeding or make the injury worse.
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Maybe, but the injury sounds way lateral. I was thinking of topicalizing the nose myself, use a little versed, get tube in nose, turn a little/a lot lateral on the bleeding side, get someone to really suction orally and then sedate with ketamine to keep breathing and drive the tube in.
Surprised no one else brought that up.
 
WheezyBaby said:
Yes I'm familiar with that table. 120 is right between II and III and a younger guy is going to be more prone to augmenting their SVR to keep their BP up
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Right. I don't see how we're disagreeing. The question is what would you use other than heart rate to identify a crashing hemorrhagic patient. The OP's case is more like your average OR neck dissection than the carotid blowout. A skilled physician can identify the difference and tailor their plan accordingly.
 
chocomorsel said:
Maybe, but the injury sounds way lateral. I was thinking of topicalizing the nose myself, use a little versed, get tube in nose, turn a little/a lot lateral on the bleeding side, get someone to really suction orally and then sedate with ketamine to keep breathing and drive the tube in.
Surprised no one else brought that up.
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One of my thoughts reading the stem was topicalization of the nares and as much of the posterior oropharynx as possible, insert a nasal tube 80-90% of the way, put the fiber though the tube, go though cords, and drive it the rest of the way home
 
Ronin786 said:
Right. I don't see how we're disagreeing. The question is what would you use other than heart rate to identify a crashing hemorrhagic patient. The OP's case is more like your average OR neck dissection than the carotid blowout. A skilled physician can identify the difference and tailor their plan accordingly.
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Maybe we're just talking past each other. Got the impression you were saying this patient would be hypotensive and significsntly altered if they had a HR of 120 from hemorrhage, think it'd be likely theyd just be clammy with a narrow PP. Agree with your overarching point
 
TimesNewRoman said:
I would have no problem with the patient going to the OR with anesthesia and ENT or trauma. Very reasonable answer. There’s a lot of reasonable choices here. I just think the “step aside lowly ER doc” attitude doesn’t help anyone.
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No one said that. You're simply not equivalent at airway skills. I don't know why that is offensive to so many EM physicians.
 
TimesNewRoman said:
Yes, I get worried. And the comments above are offensive. Have you not seen Ricky Bobby? Saying “no offense” before an offensive stament doesn’t make it not offensive. You don’t know know our average day or workflow. Spending a couple weeks in the ED as a med stud or resident isn’t a decent sample size. Further, I wasn’t talking crap, I was just pointing out there is a huge difference in anesthesiologists. We rotate trauma airways with anesthesia. I’ve seen more than one patient that was a little more tachy than I like get a big slug of prop then code by some CA2/CA3 who was too big for their britches. I generally only see attending anesthesiologists when patients crump in pacu (sometimes my patients board there) - let’s just say there seem to variable competency levels.

As far as my plan goes, I really wish I could see exactly where the holes are and see the patient (is he mega-fat/does he have a neck) First thing I would do is 1) mark the neck 2) give some product and 50 mcg fent 3) gather supplies and 4) talk him down. I have no idea how they have an EBL on someone who was shot outside the hospital, so I don’t believe that, especially given his vitals. I think you give this guy a big dose of anything and he codes. I would give the patient a yanker and ask them to suction their pharnyx as much as possible if he’s agreeable. I agree, this is urgent/emergent, but this isn’t push drugs and go since he’s not dying in front of you. I think from there you have a few options. If the wound is high end and the surgical resident is providing actual tamponade and you can fit a blade in the mouth, I think RSI isn’t crazy. My biggest concern with RSI here is that you aren’t going to be able to BVM if not immediately intubated, but that’s why you have the neck marked. Honestly, I’d consider having him hold a cmac blade if he could and taking a look at what I see with the bronchoscope.
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So you came to the Anesthesiology forum to tell us how much we worry you, that many of us aren't up to the job (in your eyes), and reveal that part of your airway plan is intubating a young otherwise healthy anxious trauma patient who's been shot in the face, awake, with little to no sedation, in the trauma bay, with him holding the blade. Cool.
 
Oh god here we go again. Can’t we all just acknowledge that there are good ER docs and bad ER docs- and good anesthesiologists and bad anesthesiologists, but *ON AVERAGE* the specialty which does airways, simple and not so simple, multiple times per day for years on end, writes books about airways, holds conferences on airways, who’s at the forefront of advanced airway device development, is, again, *ON AVERAGE*, going to better in a scenario like this?
 
vector2 said:
Oh god here we go again. Can’t we all just acknowledge that there are good ER docs and bad ER docs- and good anesthesiologists and bad anesthesiologists, but *ON AVERAGE* the specialty which does airways, simple and not so simple, multiple times per day for years on end, writes books about airways, holds conferences on airways, who’s at the forefront of advanced airway device development, is, again, *ON AVERAGE*, going to better in a scenario like this?
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EM docs write books about airway management and hold airway conferences too. But I agree, on average, the volume is not the same.


Archived Event - Levitan Airway Course

web.cvent.com web.cvent.com
 
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vector2 said:
Oh god here we go again. Can’t we all just acknowledge that there are good ER docs and bad ER docs- and good anesthesiologists and bad anesthesiologists, but *ON AVERAGE* the specialty which does airways, simple and not so simple, multiple times per day for years on end, writes books about airways, holds conferences on airways, who’s at the forefront of advanced airway device development, is, again, *ON AVERAGE*, going to better in a scenario like this?
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for the record I also wouldn’t consider attempting airway blocks and AFOI in the trauma bay for this airway. But I’m glad it worked out for the OP.
 
WheezyBaby said:
Maybe we're just talking past each other. Got the impression you were saying this patient would be hypotensive and significsntly altered if they had a HR of 120 from hemorrhage, think it'd be likely theyd just be clammy with a narrow PP. Agree with your overarching point
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Nope, you got is twisted. That was the EM/CCM doc who said that. Not Ronin.
 
Southpaw said:
No one said that. You're simply not equivalent at airway skills. I don't know why that is offensive to so many EM physicians.
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I didn't see that either, but maybe I missed it? I didn't see where this turned into EM versus Anesthesia until he/she (EM) guy said it was so. I think it's offensive to them because they are also trained to think "they" are the airway experts.
Pound for pound, we do A LOT MORE AIRWAY TOTAL than they. However, there's gotta be something to be said about the fact that they probably do MORE TRAUMATIC airways than we.
 
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chocomorsel said:
I didn't see that either, but maybe I missed it? I didn't see where this turned into EM versus Anesthesia until he/she (EM) guy said it was so. I think it's offensive to them because they are also trained to think "they" are the airway experts.
Pound for pound, we do A LOT MORE AIRWAY TOTAL than they. However, there's gotta be something to be said about the fact that they probably do more TRAUMATIC airways than we.
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The EM and anesthesia personalities and culture are very different. I personally don't like the stereotypical EM personality "I'm so cool and so bada**". They seem to attract those adrenaline junkies and they wanna do everything. Anesthesiologists honestly wanna do the least as possible lol. We make things look pretty easy most of the times. But I do have to admit, I have a lot of respect for the EM as a specialty. I have learned a lot from Levitan (who is EM trained) and EMCrit/Pulmcrit websites. I think anesthesiologists are experts at airways of course but it's true that EM will see more traumatic airways but in general, anesthesiologists see much more variety of airways. Even in the world of ENT, they are great at the surgical airway of course and FOB, but they aren't comfortable in general knowing how to safely handle a critically ill patient. That's why they are the surgical airway experts, and anesthesiologists are the non-invasive experts.
 
Katheudontas parateroumen said:
The EM and anesthesia personalities and culture are very different. I personally don't like the stereotypical EM personality "I'm so cool and so bada**". They seem to attract those adrenaline junkies and they wanna do everything. Anesthesiologists honestly wanna do the least as possible lol. We make things look pretty easy most of the times. But I do have to admit, I have a lot of respect for the EM as a specialty. I have learned a lot from Levitan (who is EM trained) and EMCrit/Pulmcrit websites. I think anesthesiologists are experts at airways of course but it's true that EM will see more traumatic airways but in general, anesthesiologists see much more variety of airways. Even in the world of ENT, they are great at the surgical airway of course and FOB, but they aren't comfortable in general knowing how to safely handle a critically ill patient. That's why they are the surgical airway experts, and anesthesiologists are the non-invasive experts.
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Agreed. Can you clarify if you are still a resident or attending though?

I know I want to do the leastest and get paid the mostest!! Who's with me?
 
Whatever. Whoever needs to feel expert on something, go home, close the door and exhibit your expertise. This arrogance on patients’ fate is unacceptable to me.
And also this etomidate thing is so ****ing ridiculous. U already hand pts to icu in a disadvantage. Show some love to their adrenals. They might save them at the end.
Just remember propofol + phenylephrine equals etomidate
 
You guys have a lot of good insights. I definitely did not mean for this to become an Anesthesia vs. EM thread.

My takeaways are that I was probably right to not sedate this guy. Whether I should have called for an in-OR awake trach is something I'll consider in the future. I figured I got a free look with an AFOI before having to go down the surgical airway route.

One of my attendings also had the good suggestion to use blow-by O2 out of the fiberscope to clear blood/secretions. I hadn't thought of this either.
 
TimesNewRoman said:
Yes, I get worried. And the comments above are offensive. Have you not seen Ricky Bobby? Saying “no offense” before an offensive stament doesn’t make it not offensive. You don’t know know our average day or workflow. Spending a couple weeks in the ED as a med stud or resident isn’t a decent sample size. Further, I wasn’t talking crap, I was just pointing out there is a huge difference in anesthesiologists. We rotate trauma airways with anesthesia. I’ve seen more than one patient that was a little more tachy than I like get a big slug of prop then code by some CA2/CA3 who was too big for their britches. I generally only see attending anesthesiologists when patients crump in pacu (sometimes my patients board there) - let’s just say there seem to variable competency levels.

As far as my plan goes, I really wish I could see exactly where the holes are and see the patient (is he mega-fat/does he have a neck) First thing I would do is 1) mark the neck 2) give some product and 50 mcg fent 3) gather supplies and 4) talk him down. I have no idea how they have an EBL on someone who was shot outside the hospital, so I don’t believe that, especially given his vitals. I think you give this guy a big dose of anything and he codes. I would give the patient a yanker and ask them to suction their pharnyx as much as possible if he’s agreeable. I agree, this is urgent/emergent, but this isn’t push drugs and go since he’s not dying in front of you. I think from there you have a few options. If the wound is high end and the surgical resident is providing actual tamponade and you can fit a blade in the mouth, I think RSI isn’t crazy. My biggest concern with RSI here is that you aren’t going to be able to BVM if not immediately intubated, but that’s why you have the neck marked. Honestly, I’d consider having him hold a cmac blade if he could and taking a look at what I see with the bronchoscope.
Click to expand...

does EM have oral boards?
 
freedeshaun2021 said:
One of my attendings also had the good suggestion to use blow-by O2 out of the fiberscope to clear blood/secretions. I hadn't thought of this either.
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I prefer to use O2 over suction for FOI, just remember to stop blowing the O2 when you get to the cords or you risk pneumothorax.
 
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Lidolover said:
Whatever. Whoever needs to feel expert on something, go home, close the door and exhibit your expertise. This arrogance on patients’ fate is unacceptable to me.
And also this etomidate thing is so ****ing ridiculous. U already hand pts to icu in a disadvantage. Show some love to their adrenals. They might save them at the end.
Just remember propofol + phenylephrine equals etomidate
Click to expand...
That is nonsense. A healthy 19 year old presenting with trauma is not going to have an adrenal crisis from etomidate and if he did hydrocortisone is relatively harmless when given in short duration. Best argument exists in sepsis however bad sepsis patients are probably going to end up on stress dose hydrocortisone anyways so not really seeing a negative there either.
 
freedeshaun2021 said:
You guys have a lot of good insights. I definitely did not mean for this to become an Anesthesia vs. EM thread.

My takeaways are that I was probably right to not sedate this guy. Whether I should have called for an in-OR awake trach is something I'll consider in the future. I figured I got a free look with an AFOI before having to go down the surgical airway route.

One of my attendings also had the good suggestion to use blow-by O2 out of the fiberscope to clear blood/secretions. I hadn't thought of this either.
Click to expand...

That guy sounds like a baller
 
chessknt said:
That is nonsense. A healthy 19 year old presenting with trauma is not going to have an adrenal crisis from etomidate and if he did hydrocortisone is relatively harmless when given in short duration. Best argument exists in sepsis however bad sepsis patients are probably going to end up on stress dose hydrocortisone anyways so not really seeing a negative there either.
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Really? Let’s then start doing all our inductions with etomidate!!! There is a reason we don’t. Before jumping into calling statements as nonsense, read the shortest version I can quote for you (since you are quite impulsive) “the butterfly effect of etomidate”. Adrenal crisis just FYI can develop in various settings, not only sepsis. and also steroid are not as harmless as you think.
Speechless.
 
Lidolover said:
Really? Let’s then start doing all our inductions with etomidate!!! There is a reason we don’t. Before jumping into calling statements as nonsense, read the shortest version I can quote for you (since you are quite impulsive) “the butterfly effect of etomidate”. Adrenal crisis just FYI can develop in various settings, not only sepsis. and also steroid are not as harmless as you think.
Speechless.
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How many ICU patients have you taken care of that got etomidate inductions? Speechless indeed maybe take your own advice about expertise...
 
chessknt said:
How many ICU patients have you taken care of that got etomidate inductions? Speechless indeed maybe take your own advice about expertise...
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Almost every pt that arrives in ICU straight from ED intubated has received etomidate. Sometimes, they get ketamine and together with that a seizure lol
 
Also I am talking with data, you are talking with personal impressions. I’m not claiming expertise on anything. The data speaks for itself.
 
Lidolover said:
Almost every pt that arrives in ICU straight from ED intubated has received etomidate. Sometimes, they get ketamine and together with that a seizure lol
Click to expand...
You think ketamine causes seizures too? 🙁

I think you might be overemphasizing small effects here in the larger picture of disease. A horribly shocked patient (which is definitely not present in this case) has a very narrow therapeutic window with induction (assuming they are stable enough to even get an induction agent). Whipping out propofol and phenylephrine for someone in, say, severe acute right heart failure from a PE is not a good move compared to ketamine or etomidate. I have yet to see any compelling evidence that etomidate does anything that impacts overall care in the ICU (including the paper you quoted which is intimating at possible effects but is relying on retrospective data analysis and all the cases were based on OR inductions and clearly the effect size is so small they need massive samples to find it).

CCM has a a huge amount of gray zone when it comes to data which is where clinical expertise comes in. Maybe in anesthesia literature there is some kind of outcomes data (I am not familiar with this) but in CCM literature there really is not compelling evidence that etomidate is going to make a patient worse so I would refrain from claiming you have the holy grail of 'data' on your side.
 
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chessknt said:
You think ketamine causes seizures too? 🙁

I think you might be overemphasizing small effects here in the larger picture of disease. A horribly shocked patient (which is definitely not present in this case) has a very narrow therapeutic window with induction (assuming they are stable enough to even get an induction agent). Whipping out propofol and phenylephrine for someone in, say, severe acute right heart failure from a PE is not a good move compared to ketamine or etomidate. I have yet to see any compelling evidence that etomidate does anything that impacts overall care in the ICU (including the paper you quoted which is intimating at possible effects but is relying on retrospective data analysis and all the cases were based on OR inductions and clearly the effect size is so small they need massive samples to find it).

CCM has a a huge amount of gray zone when it comes to data which is where clinical expertise comes in. Maybe in anesthesia literature there is some kind of outcomes data (I am not familiar with this) but in CCM literature there really is not compelling evidence that etomidate is going to make a patient worse so I would refrain from claiming you have the holy grail of 'data' on your side.
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I’m all about personalized care... and each patient is different and indeed a very very small minority might qualify for some etomidate or to state it better does not qualify for propofol (even in cardiac cases we rarely use etomidate to your surprise)...however, in the ED, every pt is induced the same way...with etomidate (and this is not an exaggeration). This is exactly what I wanted to emphasize, that not everyone needs etomidate.
regarding ketamine the literature is not conclusive. I do believe it lowers the seizure threshold and paradoxically we use ketamine infusions in the ICU for status epilepticus. Honestly speaking, I have never seen ketamine breaking a status (but who am I to reach a universal conclusion), and personally I’m opposed to using ketamine infusions for that indication. On the other hand, paramedics love ketamine and use it for intubations in the field quite often without knowing pt’s background. We have received pts in ICU seizing after ketamine induction, that being said, they could have been heading that way anyhow and ketamine helped them reach that level, who knows.
 
freedeshaun2021 said:
Created a throwaway account for this, because I've already asked for input from several people at my institution and it would be pretty easy to ID me:

Carrying the airway/trauma pager earlier this week. Get a page about "Level 1 trauma, GSW". I go down to the ED and I see dozens of people around the trauma bay, and a teenage male sitting up in a stretcher, blood pouring from his mouth. He has a GSW that entered in his R tonsil and exited the R external auditory canal. The trauma resident has a fistful of kerlix in the guy's mouth and is holding pressure to the R side of his oropharynx. She says "I have a pulsating artery just under my finger". He's apparently lost at least 400cc so far. They just gave 1U and are hanging another. The kid looks panicked but is able to nod yes/no.

The kid's vitals are as follows: HR 125, BP 98/60, RR 30, SpO2 98%. The trauma attending says "anesthesia, you're doing this one".

Discuss.
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Novel but hear me out. 20ketamine at a time, then shove in an lma awake ish. That can semi replace the tamponading finger plus hopefully divert the blood away from the airway to give you 1 shot at FOB thru the lma?

All the while have ent ready to cut the neck
 
Lidolover said:
Also I am talking with data, you are talking with personal impressions. I’m not claiming expertise on anything. The data speaks for itself.
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Data is fluid and always changing. What’s en
vogue today will be out of vogue in a decade. Or less.
I used to think like you for some years. Then I started working in the ICU and had a code w propofol and changed my tune. Those patients are tenuous and can crump quite easily.
I just give them steroids if I think they need it.
 
I for one am completely happy to handover tricky airways to the people who do it all the time. I do a lot of sick intubations, but I will never be as slick as someone who does them everyday. I wouldn’t want to touch this case. No pride when it comes to airways.

Also, ketamine doesn’t cause seizures.
 
abolt18 said:
I honestly don't think I've ever given more than 20-25mg, and that was to a stable patient coming to the OR for a scheduled case.
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The nurses at my last gig would always grow up 40 of Etomidate and I would always ask them who in the world gives 40 mg of Etomidate? And the answer would be “you’d be surprised.” That place was scary AF.
 
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