bloody airway

[anes121508]

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I'm a student doing ICU month....

Called to the floor for a patient h/o pancreatic CA with respiratory difficulty secondary to possible PE (report from the floor resident).

Get to the room. Last time the cuff recycled 70's/40's, last sat recorded mid eighties (nobody now can get the pulse ox to work).

Patient has decreased level of consciousness, looks like he struggling to breath. not obviously coughing anything up.

ICU resident quickly decides to transfer to the ICU. Respiratory therapy bagging patient on way to ICU.

No read on the BP or sat when we get to the ICU. Resident let's me attempt intubation. Fentanyl, Versed given. I used a MAC, see epiglottis and nothing but serosanguineous fluid and no arytenoids or cords. Suction, suction, suction. Resident has me pull out to bag the patient. Still no sat on our monitor. Glidescope on attempt number two. Tons of bloody fluid. Suctions works quicker this time. We both think tube goes through the cords on the screen. No color change on the end tidal CO2 detector. Can hardly hear any breath sounds. Doesn't sound like it's in the stomach. Tube pulled out. Glide Scope by senior resident and tube goes through the cords. on the screen. No color change on the CO2 detector. Still can't hear breath sounds. Suction down through the tube and tons of blood comes out. Few more seconds of suctioning through the tube and more blood. Back to bagging. Still no sats. ICU attending uses fiberoptic scope and can't see anything. PT codes, CPR, defib, meds. 30 min of coding the patient attending calls it.

Since I'm new to this I probably left out tons of details that are important and relevant in the decision making process. Everything happened extremely fast. (already quite overwhelmed on my ICU month)

In a patient with this much blood (presumably filling the lungs), is it possible that we were never even able to oxygenate him despite the fact that we thought the tube was in the correct place? Should I have seen some type of sat pop up on the monitor? Or was it just a pulse ox issue? What else could we have done for the pulmonary bleeding besides suction, bag, suction, bag? Seems like we were already way behind the eight ball from the very beginning.

thanks...

I

 

[nycitygas]

I'm a student doing ICU month....

Called to the floor for a patient h/o pancreatic CA with respiratory difficulty secondary to possible PE (report from the floor resident).

Get to the room. Last time the cuff recycled 70's/40's, last sat recorded mid eighties (nobody now can get the pulse ox to work).

Patient has decreased level of consciousness, looks like he struggling to breath. not obviously coughing anything up.

ICU resident quickly decides to transfer to the ICU. Respiratory therapy bagging patient on way to ICU.

No read on the BP or sat when we get to the ICU. Resident let's me attempt intubation. Fentanyl, Versed given. I used a MAC, see epiglottis and nothing but serosanguineous fluid and no arytenoids or cords. Suction, suction, suction. Resident has me pull out to bag the patient. Still no sat on our monitor. Glidescope on attempt number two. Tons of bloody fluid. Suctions works quicker this time. We both think tube goes through the cords on the screen. No color change on the end tidal CO2 detector. Can hardly hear any breath sounds. Doesn't sound like it's in the stomach. Tube pulled out. Glide Scope by senior resident and tube goes through the cords. on the screen. No color change on the CO2 detector. Still can't hear breath sounds. Suction down through the tube and tons of blood comes out. Few more seconds of suctioning through the tube and more blood. Back to bagging. Still no sats. ICU attending uses fiberoptic scope and can't see anything. PT codes, CPR, defib, meds. 30 min of coding the patient attending calls it.

Since I'm new to this I probably left out tons of details that are important and relevant in the decision making process. Everything happened extremely fast. (already quite overwhelmed on my ICU month)

In a patient with this much blood (presumably filling the lungs), is it possible that we were never even able to oxygenate him despite the fact that we thought the tube was in the correct place? Should I have seen some type of sat pop up on the monitor? Or was it just a pulse ox issue? What else could we have done for the pulmonary bleeding besides suction, bag, suction, bag? Seems like we were already way behind the eight ball from the very beginning.

thanks...

I

I'm suprised the resident would let a student (no offense to you of course) intubate a patient in such a condition.

I had a similar case when we couldn't bag a patient after we induced. She was brought up for respiratory distress-turned out she had a carotid blowout from a huge fungating tumor. As soon as we put the blade in all we saw was blood blood. Even after the tube was placed there was barely detectable etCO2.

I dont think there was anything you could have differently at that point other than keep suctioning the tube.

 

[Green Chimneys]

If this was pulmonary hemorrhage, 2 reasons:

1. No gas exchange and no breath sounds because the lungs were full of blood

2. No gas exchange because cardiac output was kaput. Incidentally, this is the same reason your pulse ox and BP cuff "weren't working."

This guy needed CPR, ACLS, ET suction, and bronchoscopy to suck all the 'ish out of his lungs and try to isolate the bleed. Given his disease process, it probably wasn't something you were going to fix.

 

[Rotors]

1. No gas exchange and no breath sounds because the lungs were full of blood

2. No gas exchange because cardiac output was kaput. Incidentally, this is the same reason your pulse ox and BP cuff "weren't working."

This.

Also, the fact you were using a piece of crap colourmetric CO2 detector is a bit concerning; do you not have waveform capnography?

Now I'm not an Anaesthetist nor an Intensivest but intubating somebody with "sedation" using only fentanyl and midazolam is extremely frowned upon here and I have never seen it done nor heard of anybody doing it.

Propofol (or ketamine for the haemodynamically unstable patient) +/- suxamethonium is the standard mix to tube somebody here.

 

[Green Chimneys]

There was nothing wrong the choice of induction, nor the use of a disposable piece of equipment to confirm gas exchange, Rotors. Your post is very condescending and comes from minimal knowledge base. Your condescension is especially unwarranted considering the OP is a student trying to understand a situation in which he was involved but was not calling the shots.

OP, sounds like all the appropriate interventions were taken in some way, shape, or form. Sometimes a terminal disease process is just that.

 

[Rotors]

If this guy wants to learn how to tube he needs to learn to do it properly or not at all. I understand as a student he may at the bottom of the food chain and it is the decision of the Registrar or Consultant how to proceed. I am quite surprised he was even allowed to attempt to tube; it is generally considered that intubating a patient who is critically unwell is the job of the Registrar or Consultant, even the House Officer is generally not considered an appropriate person to tube somebody, let alone a student.

Sedation only intubation was withdrawn from where I am specifically because it was felt to be inappropriate and inferior to intubation with paralysis. Intubation with paralysis is standard in the emergency department, the operating theatre and ICU; waveform capnography is also compulsory. The Ambulance Service has withdrawn sedation only intubation and colourmetric ETCO2 detectors for Intensive Care Paramedics and replaced it with RSI.

The overwhelming majority of our ICU intubations are performed by an Anaesthetist or Anaesthetic Registrar; an Intensivest is not an Anaesthetist.

I'm not on this bloke's case specifically but he should be aware there are far better ways to tube somebody than with some fentanyl and a bit of midazolam; especially somebody who is critically unwell.

 

[Per4mer8]

 

[fakin' the funk]

Called to the floor for a patient h/o pancreatic CA with respiratory difficulty secondary to possible PE (report from the floor resident).

Get to the room. Last time the cuff recycled 70's/40's, last sat recorded mid eighties (nobody now can get the pulse ox to work).

Patient has decreased level of consciousness, looks like he struggling to breath. not obviously coughing anything up.

ICU resident quickly decides to transfer to the ICU. Respiratory therapy bagging patient on way to ICU.

No read on the BP or sat when we get to the ICU. Resident let's me attempt intubation. Fentanyl, Versed given. I used a MAC, see epiglottis and nothing but serosanguineous fluid and no arytenoids or cords. Suction, suction, suction. Resident has me pull out to bag the patient. Still no sat on our monitor. Glidescope on attempt number two. Tons of bloody fluid. Suctions works quicker this time. We both think tube goes through the cords on the screen. No color change on the end tidal CO2 detector. Can hardly hear any breath sounds. Doesn't sound like it's in the stomach. Tube pulled out. Glide Scope by senior resident and tube goes through the cords. on the screen. No color change on the CO2 detector. Still can't hear breath sounds. Suction down through the tube and tons of blood comes out. Few more seconds of suctioning through the tube and more blood. Back to bagging. Still no sats. ICU attending uses fiberoptic scope and can't see anything. PT codes, CPR, defib, meds. 30 min of coding the patient attending calls it.

Since I'm new to this I probably left out tons of details that are important and relevant in the decision making process. Everything happened extremely fast. (already quite overwhelmed on my ICU month)

In a patient with this much blood (presumably filling the lungs), is it possible that we were never even able to oxygenate him despite the fact that we thought the tube was in the correct place? Should I have seen some type of sat pop up on the monitor? Or was it just a pulse ox issue? What else could we have done for the pulmonary bleeding besides suction, bag, suction, bag? Seems like we were already way behind the eight ball from the very beginning.

Your questions seem to focus in on the poor functioning of the monitors you were using and the specifics of those -- why didn't the pulse-ox work, why didn't the etCO2 work, etc. The uses and limitations of those monitors are good things to know BEFORE you get into active roles in these situations -- not that you can go back and do it all over again, but going forward, those are good things to know.

Overall this pt's condition was horrible and there was likely little you could do. When you arrive at a peri-code scene like that, you do the usual ABC's, in this case it sounded like airway and breathing were OK at least at first and circulation was the main issue. Hemorrhage and PE sound like a reasonable differential to start. It would have been reasonable IMO to call a code on the floor to muster additional help and resources before transfer; blood, monitor, pressors etc.

As far as your airway details, pretty typical stuff:
1) aggressive positive pressure ventilation in a pt with GI pathology (full stomach) --> high likelihood of regurgitation/aspiration
2) ETT in the trachea without cardiac output --> no etCO2
3) lots of aspirate/blood in airway --> massive shunt --> profound hypoxemia
4) venous desaturation in a peri-coding patient also with shunt --> profound hypoxemia
5) no pulse --> no pulse-ox

As far as what you can do about pulmonary hemorrhage, if there is a focal source, you can block that lung or lobe with some fancy techniques and equipment.

But in this case, probably not the main issue.

People who are going to die of cancer have to do it somehow, ya know. PE ain't that bad of a way to do it.

 

[BobBarker]

Earlier compressions.

So you give a paralytic to every bloke who is already dead and needs a tube? In the US, we intubate without paralytics routinely. If the pt is already floppy, whats the point? I probably had around 30 floor intubations as an intern and had to give succ only twice. Both times were for jaw clinching post etomidate.

 

[pd4emergence]

If this guy wants to learn how to tube he needs to learn to do it properly or not at all. I understand as a student he may at the bottom of the food chain and it is the decision of the Registrar or Consultant how to proceed. I am quite surprised he was even allowed to attempt to tube; it is generally considered that intubating a patient who is critically unwell is the job of the Registrar or Consultant, even the House Officer is generally not considered an appropriate person to tube somebody, let alone a student.

Sedation only intubation was withdrawn from where I am specifically because it was felt to be inappropriate and inferior to intubation with paralysis. Intubation with paralysis is standard in the emergency department, the operating theatre and ICU; waveform capnography is also compulsory. The Ambulance Service has withdrawn sedation only intubation and colourmetric ETCO2 detectors for Intensive Care Paramedics and replaced it with RSI.

The overwhelming majority of our ICU intubations are performed by an Anaesthetist or Anaesthetic Registrar; an Intensivest is not an Anaesthetist.

I'm not on this bloke's case specifically but he should be aware there are far better ways to tube somebody than with some fentanyl and a bit of midazolam; especially somebody who is critically unwell.

Here anesthesia has the good stuff (propofol,ketamine,relaxants). My guess is it went something like this....get to the icu...ask for drugs...nurse says all I can get quickly is x....ok then we will have to use x....here an anesthesiologist doesn't respond to every code and a lot of times by the time we get there the airway has been secured. Our units don't routinely have ketamine or sux or any other relaxants readily on hand.

Also, I am always very careful when giving sux to a patient I basically know nothing about (which is nearly all floor or icu intubations I perform). Alot of times I get to the room, ask for the patients history and get a blank stare. I go through the chart if I have time but it is a quick review. I can easily miss a contraindication.

 

[imfrankie]

"Critically Unwell" ...I gotta move to NZ

 

[jwk]

This.

Also, the fact you were using a piece of crap colourmetric CO2 detector is a bit concerning; do you not have waveform capnography?

Now I'm not an Anaesthetist nor an Intensivest but intubating somebody with "sedation" using only fentanyl and midazolam is extremely frowned upon here and I have never seen it done nor heard of anybody doing it.

Propofol (or ketamine for the haemodynamically unstable patient) +/- suxamethonium is the standard mix to tube somebody here.

There are lots of right ways to do things besides the way they're done in NZ.

Colorimetric CO2 detectors are pretty standard on code-carts throughout the US. They're quick, easy, dependable, and CHEAP. It would be prohibitively expensive to add an EtCO2 monitor to every code cart.

Simply because you've never seen intubation done with sedation only, fentanyl/midazolam or otherwise, does not mean it's not done. This patient probably could have been intubated pretty easily with no sedation or NMB's.

I think the other thing worth mentioning here is that consideration should have been given to intubating the patient immediately when they were found in extremis rather than taking the time to transport them before doing anything definitive. They were already at death's door before they were moved. Transporting a patient in this poor condition without securing their airway allowed them to get that much closer to the edge.

 

[bigdan]

OP -

http://www.youtube.com/watch?v=XOVS_SYyXe8

 

[Rotors]

So you give a paralytic to every bloke who is already dead and needs a tube? In the US, we intubate without paralytics routinely. If the pt is already floppy, whats the point? I probably had around 30 floor intubations as an intern and had to give succ only twice. Both times were for jaw clinching post etomidate.

Without asking every Emergency Physician and Anaesthetist in the country I can't say for sure but yes, I have never seen anybody intubated without paralysis, nor heard of it, nor has any Emergency Physician nor Anaesthetist I've asked ever said it was something they would do, in fact quite the contrary.

If somebody is a "tough tube" we'll get the Anaesthetist or Anaesthetic Registrar down to tube them.

here an anesthesiologist doesn't respond to every code and a lot of times by the time we get there the airway has been secured. Our units don't routinely have ketamine or sux or any other relaxants readily on hand.

How interesting; I'm not saying it's a bad thing but how very different.

In some hospitals here an Anaesthetist or Anaesthetic Registrar +/- Technician responds to a resus page in others they only respond if called; however generally in New Zealand if somebody on the ward/ HDU or ICU is really crook and needs a tube then the Anaesthetist is called.

In ED you just get tubed down there however as I said above if the patient is really crook or the ED Doc feels out of their comfort zone they'll have an Anaesthetist or the Anaesthetic Registrar come down and do it.

Also, I am always very careful when giving sux to a patient I basically know nothing about (which is nearly all floor or icu intubations I perform). Alot of times I get to the room, ask for the patients history and get a blank stare. I go through the chart if I have time but it is a quick review. I can easily miss a contraindication.

I certainly think that is a very good approach i.e. better safe than sorry

The balance of risk is probably in favour of giving suxamethonium unless there are obvious contraindications; i.e. FHx of malignant hyperthermia, hyperkalaemia or muscle wasting disease or giving vecuronium if you're concerned about MH or hyperkalaemia.

"Critically Unwell" ...I gotta move to NZ

Sure thing come on down y'all we need more Consultant Emergency Physicians!

We also have the diagnosis of "Super Crook (TM)"

It would be prohibitively expensive to add an EtCO2 monitor to every code cart.

Simply because you've never seen intubation done with sedation only, fentanyl/midazolam or otherwise, does not mean it's not done. This patient probably could have been intubated pretty easily with no sedation or NMB's.

I agree there are plenty of different ways to do things but you are correct I have never seen it done no, and we are taught it is absolutely akin to some form of satanic devil worship.

Do your crash carts not have a Lifepak or other similar monitor/defibrillator? I know Lifepak and Phillips both make them with built in ETCO2.

I think the other thing worth mentioning here is that consideration should have been given to intubating the patient immediately when they were found in extremis rather than taking the time to transport them ....

This.

 

[Gern Blansten]

If this guy wants to learn how to tube he needs to learn to do it properly or not at all. I understand as a student he may at the bottom of the food chain and it is the decision of the Registrar or Consultant how to proceed. I am quite surprised he was even allowed to attempt to tube; it is generally considered that intubating a patient who is critically unwell is the job of the Registrar or Consultant, even the House Officer is generally not considered an appropriate person to tube somebody, let alone a student.

Sedation only intubation was withdrawn from where I am specifically because it was felt to be inappropriate and inferior to intubation with paralysis. Intubation with paralysis is standard in the emergency department, the operating theatre and ICU; waveform capnography is also compulsory. The Ambulance Service has withdrawn sedation only intubation and colourmetric ETCO2 detectors for Intensive Care Paramedics and replaced it with RSI.

The overwhelming majority of our ICU intubations are performed by an Anaesthetist or Anaesthetic Registrar; an Intensivest is not an Anaesthetist.

I'm not on this bloke's case specifically but he should be aware there are far better ways to tube somebody than with some fentanyl and a bit of midazolam; especially somebody who is critically unwell.

I have to assume you are talking about a totally different patient population than the OP is referring to. The OP describes a patient that is rapidly going down the tubes. They don't need an induction dose of propofol and succinylcholine to put the tube in. An induction dose of most drugs in this situation (low sats, no BP, on the brink of C/V collapse) will likely be a clean kill. I hope that you are not saying that you would arrive at a code with a minimally responsive patient that had no BP and terrible sats and proceed with giving propofol and succinylcholine. I really hope you are not saying that. I don't think your mentors in New Zealand would like you speaking for them in this manner because I feel quite certain that they would not do that either.

I think the patient you are talking about is the cardiovascularly stable patient that needs intubated, but is awake and not actively dying. Certainly, those patients, in most cases, would be given appropriate doses of anesthetic drugs +/- NMB's.

Is that what you mean?

 

[Gern Blansten]

Just saw your other response. I think the patient in the original post was "super crook."

 

[Gern Blansten]

Bad memories are better than no memories

 

[PMPMD]

Without asking every Emergency Physician and Anaesthetist in the country I can't say for sure but yes, I have never seen anybody intubated without paralysis, nor heard of it, nor has any Emergency Physician nor Anaesthetist I've asked ever said it was something they would do, in fact quite the contrary.

Then you haven't had to intubate many asystolic patients.

As residents ("registrars"), we responded to all the cardiac arrests. We had to call the attending ("consultant") to get permission to use neuromuscular blockers. In dozens and dozens of codes, I only needed NMBs once for a patient who wasn't quite well enough to transfer to ICU first, and not quite sick enough for good old Brutane.

 

[Rotors]

Then you haven't had to intubate many asystolic patients.

The OP did not say this patient was in cardiac arrest only that they could not detect a blood pressure or an SPO2; automated blood pressure cuffs are rubbish when the patient is very hypotensive. He said the patient went on to have a cardiac arrest; so in the intervening time period between arriving in the ICU and the patient having a cardiac arrest the picture painted was of a critically unwell patient who at least had some sort of intact cardiovascular state, allbeit doesn't sound like much of one.

As residents ("registrars"), we responded to all the cardiac arrests. We had to call the attending ("consultant") to get permission to use neuromuscular blockers. In dozens and dozens of codes, I only needed NMBs once for a patient who wasn't quite well enough to transfer to ICU first, and not quite sick enough for good old Brutane.

See you're talking about somebody who is in cardiac arrest; the only person I'd ever intubate who is in cardiac arrest is somebody who has had a secondary cardiac arrest because they've been traumatically asphyxiated or something of that nature to cause their cardiac arrest. Intubation in cardiac arrest has been progressively de-emphasised here over the past few years in preference to the LMA both for the in-hospital arrest and by the Ambulance Service for their Intensive Care Paramedics. I had a quick review of Circulation (AHA ECC Guidelines 2010) just to make sure I wasn't talking out my rectum (see here http://circ.ahajournals.org/content/122/18_suppl_3/S729.full.pdf+html)

I have to assume you are talking about a totally different patient population than the OP is referring to

If I was then why would I bring it up here? That'd be like asking the Surgical House Officer for an admission opinion on somebody with a Psychiatric problem!

I hope that you are not saying that you would arrive at a code with a minimally responsive patient that had no BP and terrible sats and proceed with giving propofol and succinylcholine. I really hope you are not saying that.

No, I wouldn't touch this guy with propofol nor etomidate, thiopentone or good old fashioned open drop ether for that matter either (despite being a buff for anaesthesia history!). All of them have unacceptable cardiovascular risk profile for somebody who is mega crook. Ketamine is really wonderful on the other hand.

And yes, there are no contraindications to suxamethonium in this patient.

I don't think your mentors in New Zealand would like you speaking for them in this manner because I feel quite certain that they would not do that either.

You are welcome to solicit an opinion from ANZCA or ACEM on the issue however none of my "mentors" (all of whom bar one have been Consultant Physicians) have ever taught or advocated anything other than intubation with anaesthesia and paralysis; and yes, that includes people who are critically unwell.

I think the patient you are talking about is the cardiovascularly stable patient that needs intubated, but is awake and not actively dying. Certainly, those patients, in most cases, would be given appropriate doses of anesthetic drugs +/- NMB's.

Is that what you mean?

No if I meant to talk about a "cardiovascularly stable patient that needs intubated, but is awake and not actively dying" then I'd go find or start a thread about one of them.

I'm referring to somebody who is super bloody crook and fixing to drop dead who needs an airway.

Now I am highly interested to know how long passed and what sort of oxygenation was provided between the multiple intubation attempts.

You're welcome to dismiss me as a funny talking bloke from the bottom of the world and if you wish to do so go right ahead I won't mind, but I can find no reference to the process you speak of (intubating without paralysis) in any anaesthesia text I have nor have I ever seen it (but that doesn't mean it's not an actual thing, sounds like you blokes do it) and in fact I've spoken to three Consultant Physicians regarding it because they are far more expertly than I on this subject; two Anaesthetists and one Emergency Physician, all agreed it should not be done and one of the Anaesthetists looked rather ill at the notion it was being performed.

So I guess we can agree to disagree or something.

Oh and unrelated but perhaps my Google-fu is weak but is Intensive Care Medicine even a recognised speciality in the US? It appears not as I can find no reference to a specialist College; who runs the ICUs in your part of the world?

 

[cincincyreds]

For the autopsy, I would highly recommend making sure that ETT is actually in the trachea and not in the stomach. That wouldn't be a pretty law suit.

 

[PMPMD]

Oh and unrelated but perhaps my Google-fu is weak but is Intensive Care Medicine even a recognised speciality in the US? It appears not as I can find no reference to a specialist College; who runs the ICUs in your part of the world?

Critical Care is indeed a recognized specialty by the American Board of Medical Specialties. It is not a primary specialty but rather a subspecialty of other fields. For adults, ICUs can be run by:
Internal medicine - usually also pulmonologists.
Surgery - usually also trauma surgeons
Anesthesiologists.
Neurologists (and neurosurgeons?) can do a neuro-critical care fellowship.
Also, emergency medicine has subspecialty certification in critical care.

For kids, pediatricians can do peds critical care or neonatology fellowships.

http://www.abms.org/who_we_help/physicians/specialties.aspx

Approved ABMS Member Board
General Certificate(s) Subspecialty Certificates

American Board of Anesthesiology
Anesthesiology Critical Care Medicine

American Board of Emergency Medicine
Emergency Medicine Critical Care Medicine

American Board of Internal Medicine

Internal Medicine Critical Care Medicine

American Board of Obstetrics and Gynecology
Obstetrics and Gynecology Critical Care Medicine

American Board of Pediatrics
Pediatrics Pediatric Critical Care Medicine

American Board of Surgery
Surgery Surgical Critical Care

According to the ABMS site, OB/Gyn has a subspecialty certificate in critical care but I've never heard of this before - anyone else?

 

[PMPMD]

The OP did not say this patient was in cardiac arrest only that they could not detect a blood pressure or an SPO2; automated blood pressure cuffs are rubbish when the patient is very hypotensive. He said the patient went on to have a cardiac arrest; so in the intervening time period between arriving in the ICU and the patient having a cardiac arrest the picture painted was of a critically unwell patient who at least had some sort of intact cardiovascular state, allbeit doesn't sound like much of one.

You stated

Without asking every Emergency Physician and Anaesthetist in the country I can't say for sure but yes, I have never seen anybody intubated without paralysis, nor heard of it, nor has any Emergency Physician nor Anaesthetist I've asked ever said it was something they would do, in fact quite the contrary.

I was providing a common scenario in which patients are indeed intubated without paralysis.

See you're talking about somebody who is in cardiac arrest; the only person I'd ever intubate who is in cardiac arrest is somebody who has had a secondary cardiac arrest because they've been traumatically asphyxiated or something of that nature to cause their cardiac arrest. Intubation in cardiac arrest has been progressively de-emphasised here over the past few years in preference to the LMA both for the in-hospital arrest and by the Ambulance Service for their Intensive Care Paramedics. I had a quick review of Circulation (AHA ECC Guidelines 2010) just to make sure I wasn't talking out my rectum (see here http://circ.ahajournals.org/content/122/18_suppl_3/S729.full.pdf+html)

See this recent thread about the new protocol. You're completely misunderstanding the concept here. It's not that the patients shouldn't be intubated; it's that compressions/defibrillation should not be delayed for airway management. In multiple resuscitator model such as the case described, it's appropriate to secure an airway. This is completely different than pre-hospital arrests. In that situation, the transfer of the patient to a higher level of care should not be delayed for attempts at airway management by less skilled providers.

 

[Rotors]

Critical Care is indeed a recognized specialty by the American Board of Medical Specialties. It is not a primary specialty but rather a subspecialty of other fields

Ah, that is how it used to be here up until about 10-15 years ago; Intensive Care Medicine was a sub-Faculty of the Australia + NZ College of Anaesthetists.

Now it's a primary speciality with a recognised vocational training program leading to Fellowship as an Intensivest or FJCICM.

I was providing a common scenario in which patients are indeed intubated without paralysis.

Yeah OK sorry I guess since we don't really ever intubate cardiac arrests any more its default thinking somebody who needs intubating is not in cardiac arrest and will need anaesthetising and paralysing first.

In multiple resuscitator model such as the case described, it's appropriate to secure an airway.

I'm not going to hijack the post to discuss intubation in cardiac arrest except to say that here intubation in primary cardiac arrest has been massively de-emphasised with preference being given to the LMA.

This is completely different than pre-hospital arrests. In that situation, the transfer of the patient to a higher level of care should not be delayed for attempts at airway management by less skilled providers.

You may be interested to know that here if Paramedics deem resuscitation in the best interest of the arrested patient so work them but no ROSC is achieved the patient is not transported and an Intensive Care Paramedic can sign the life extinct certificate for the Police.

We have never transported primary cardiac arrests and will not be starting any time soon.

 

[IlDestriero]

This.

Also, the fact you were using a piece of crap colourmetric CO2 detector is a bit concerning; do you not have waveform capnography?

Now I'm not an Anaesthetist nor an Intensivest but intubating somebody with "sedation" using only fentanyl and midazolam is extremely frowned upon here and I have never seen it done nor heard of anybody doing it.

Propofol (or ketamine for the haemodynamically unstable patient) +/- suxamethonium is the standard mix to tube somebody here.

When the patient is already dead, and it sounds like he was, his heart just didn't know it yet, you don't need anything to intubate. Though I would have managed this patient much differently.
If you come in as an unresponsive trauma, or you call me for a code and you're doing chest compressions, etc. I'll just place the tube, no meds.

 

[Apollyon]

You may be interested to know that here if Paramedics deem resuscitation in the best interest of the arrested patient so work them but no ROSC is achieved the patient is not transported and an Intensive Care Paramedic can sign the life extinct certificate for the Police.

We have never transported primary cardiac arrests and will not be starting any time soon.

That is true in various locales in the US. In New York state, we were divided into 13 regions for ALS (paramedics) (there are now 18 regional councils). The basic life support (BLS) protocols were statewide. Our regional authority wrote our ALS protocols (which were different with each region - there was much overlap, but none were identical).

In 1996 - 16 years ago - we had protocols for cardiac arrests that went as follows: asystole, intubated, epi 1mg, atropine 1mg - if no ROSC, we had the option of terminating with online medical control (via cellular phone). It's not a new thing, and it's variable across the US. I can't speak for other states (even where I am licensed as a physician), but some have to bring in every code that does not fit "obvious death" criteria (rigor/livor mortis, corporal dismemberment, exposed brain matter, decomposition), whereas others have the ability to code and call the arrest in the field without online medical direction, and the range falls in between both extremes.

 

[anes121508]

I really appreciate the the responses. I am still working so cant wite back yet, but this is exactly the discussion I was hoping to stimulate. From whether or not i should have been doing this to the pending autopsy to basic questions about the airway.

 

[Rotors]

In 1996 - 16 years ago - we had protocols for cardiac arrests that went as follows: asystole, intubated, epi 1mg, atropine 1mg - if no ROSC, we had the option of terminating with online medical control (via cellular phone). It's not a new thing, and it's variable across the US. I can't speak for other states (even where I am licensed as a physician), but some have to bring in every code that does not fit "obvious death" criteria (rigor/livor mortis, corporal dismemberment, exposed brain matter, decomposition), whereas others have the ability to code and call the arrest in the field without online medical direction, and the range falls in between both extremes.

You may be interested to know we do not have "protocols" or "online medical control"

Our criteria for commencing resuscitation is basically "is resuscitating this person in the best interest of the patient?"; clearly some situation are not; i.e. where it is futile e.g. obvious death, injuries incompatible with life, unwitnessed arrest with aystole as initial rhythm or not in best interest of patient e.g. end stage terminal illnesses

The latter applies both in hospital and out of hospital

 

[vector2]

I really appreciate the the responses. I am still working so cant wite back yet, but this is exactly the discussion I was hoping to stimulate. From whether or not i should have been doing this to the pending autopsy to basic questions about the airway.

Interesting case...make sure you f/u on the autopsy cause I'm sure inquiring minds want to know. Also, as an MS4 who's done three anesthesia rotations I've gotta say I'm still very surprised you were the first person to take a look at the airway. I've gotten to take a crack at floor intubations on pts who were in moderate resp distress, but never on a guy who's profoundly hypotensive, satting in the 80s and about to arrest.

 

[Trisomy13]

Without asking every Emergency Physician and Anaesthetist in the country I can't say for sure but yes, I have never seen anybody intubated without paralysis, nor heard of it, nor has any Emergency Physician nor Anaesthetist I've asked ever said it was something they would do, in fact quite the contrary.
.

All I can surmise from this is that you have not seen enough intubations in different scenarios.

 

[Gern Blansten]

The age old question that seems to be a turf battle in many teaching hospitals. Do you let the most experienced person take the initial look for a trauma or code intubation?
There is a dilemma, because it is a teaching hospital.
In fact, however, I would argue that often times our anesthesia lower level resident IS the most experienced person at a code and has probably intubated more than an ED attending or an upper level ED resident and certainly more than any of the medicine folks (residents, fellows, or attendings).
The med student was put in a tough spot. He was offered the chance and he took it. Had he refused, his attending may have seen that as weak and formed a poor opinion. As it stands, the attempt was uncertain as to success due to confounding factors related to the patient. So the student is still portrayed in a negative light for the attending (possibly, I don't really know). The student was put in a situation where it would have been difficult to shine. The bloke was obviously super crook.

 

[vector2]

The age old question that seems to be a turf battle in many teaching hospitals. Do you let the most experienced person take the initial look for a trauma or code intubation?
There is a dilemma, because it is a teaching hospital.
In fact, however, I would argue that often times our anesthesia lower level resident IS the most experienced person at a code and has probably intubated more than an ED attending or an upper level ED resident and certainly more than any of the medicine folks (residents, fellows, or attendings).
The med student was put in a tough spot. He was offered the chance and he took it. Had he refused, his attending may have seen that as weak and formed a poor opinion. As it stands, the attempt was uncertain as to success due to confounding factors related to the patient. So the student is still portrayed in a negative light for the attending (possibly, I don't really know). The student was put in a situation where it would have been difficult to shine. The bloke was obviously super crook.

Make no mistake, as a student I would've jumped at the opportunity in a heartbeat. But that being said, I take 'teaching hospital' to mean that junior residents typically get the first shot at most things and then the student if there's some extra left over. I think it's a bit shady and reflects somewhat poorly on the senior/attending to let even an experienced student take first shot at DL when conceivably seconds matter, not minutes.

 

[Gern Blansten]

Make no mistake, as a student I would've jumped at the opportunity in a heartbeat. But that being said, I take 'teaching hospital' to mean that junior residents typically get the first shot at most things and then the student if there's some extra left over. I think it's a bit shady and reflects somewhat poorly on the senior/attending to let even an experienced student take first shot at DL when conceivably seconds matter, not minutes.

I agree. I would not, however, have any problem letting a CA-1 do the airway after they have worked in the OR a couple months and done quite a few intubations.

 

[Apollyon]

You may be interested to know we do not have "protocols" or "online medical control"

I don't know how EMS exists in NZ. Your condescending tone is duly noted, and you can stuff it. Paramedics in the US have protocols to follow (just like corpsmen/medics in the US military). I guess it's good for the paramedics if they don't have a doctor they can call for questions. As I don't know the education level, I can't say if it is good for patients.

 

[repititionition]

Propofol (or ketamine for the haemodynamically unstable patient) +/- suxamethonium is the standard mix to tube somebody here.

The balance of risk is probably in favour of giving suxamethonium unless there are obvious contraindications; i.e. FHx of malignant hyperthermia, hyperkalaemia or muscle wasting disease or giving vecuronium if you're concerned about MH or hyperkalaemia.

And yes, there are no contraindications to suxamethonium in this patient.

Main takeaway so far: you know how to spell suxamethonium. We get it.

 

[Idiopathic]

I intubate these patients wherever they are found, then transport them to their ICU. Nowhere in the ABC/CAB algorithm does it mention T (transport), and this patient was clearly dying before you passed the tube.

this is probably pulmonary edema coupled with traumatic intubation times 2 or 3, its unlikely to be frank pulmonary hemorrhage.

oh and absolutely nothing wrong with giving the pulseless or obtunded patient (sounds like this guy could have been either) some variety of whatever induction cocktail you deem appropriate (ive used sux only, versed only, nothing...it depends on the situation)

 

[Lightwand]

Just a note for the OP, if your monitors aren't working, assume the problem is with what you're trying to monitor, rather than with the machine. Check the patient first, then the monitor. I routinely have my finger on the carotid when I show up at a situation like the one you described- you can become remarkably good at determining approximate BP by palpating a pulse after a few years of experience. Gives you information much faster than waiting for a cuff to cycle or someone to try and find a manual cuff.

Sounds like this guy should have probably had some epi before he required full-blown CPR. Also sounds like he was going down the tubes before you got involved and the outcome would probably have been similar in any situation, whether it happened then or in the next four hours.

And I agree with those who said that you probably didn't get color change because of a lack of cardiac output (same issue as no BP or pulse ox). The tube was probably in the right spot, especially if you had direct visualization on the Glidescope screen with experienced providers.

And for the paralytic/no paralytic debate, I'm VERY hesitant to push sux for an emergent airway if nobody can give me history. If it's a matter of getting the airway vs not, I'll do it, but I don't routinely use paralytic at remote (floor, ICU) airways, unless I have an attending with me. Pushing sux in someone with unknown history scares me- especially someone who is septic, acidotic and maybe in ARF. That's just my take.

 

[WholeLottaGame7]

Just a note for the OP, if your monitors aren't working, assume the problem is with what you're trying to monitor, rather than with the machine. Check the patient first, then the monitor. I routinely have my finger on the carotid when I show up at a situation like the one you described- you can become remarkably good at determining approximate BP by palpating a pulse after a few years of experience. Gives you information much faster than waiting for a cuff to cycle or someone to try and find a manual cuff.

Sounds like this guy should have probably had some epi before he required full-blown CPR. Also sounds like he was going down the tubes before you got involved and the outcome would probably have been similar in any situation, whether it happened then or in the next four hours.

And I agree with those who said that you probably didn't get color change because of a lack of cardiac output (same issue as no BP or pulse ox). The tube was probably in the right spot, especially if you had direct visualization on the Glidescope screen with experienced providers.

And for the paralytic/no paralytic debate, I'm VERY hesitant to push sux for an emergent airway if nobody can give me history. If it's a matter of getting the airway vs not, I'll do it, but I don't routinely use paralytic at remote (floor, ICU) airways, unless I have an attending with me. Pushing sux in someone with unknown history scares me- especially someone who is septic, acidotic and maybe in ARF. That's just my take.

Agree.

 

[Idiopathic]

And for the paralytic/no paralytic debate, I'm VERY hesitant to push sux for an emergent airway if nobody can give me history. If it's a matter of getting the airway vs not, I'll do it, but I don't routinely use paralytic at remote (floor, ICU) airways, unless I have an attending with me. Pushing sux in someone with unknown history scares me- especially someone who is septic, acidotic and maybe in ARF. That's just my take.

I was like you as a resident, and now its on a case by case basis depending on how difficult I think the airway will be. Rocuronium is appropriate and will make your visualization and intubation easier, no doubt about it. Unless you are worried about a difficult airway, paralytic is your friend in these situations, and Ive gotten more accustomed to giving it for floor intubations. We are probably more worried about sux in this setting then we should be, if no history of burn/spinal cord injury/etc then its probably safe.

 

[MRW]

Great thread!

I have added "super crook" to my peri-operative lexicon.

 

[Gern Blansten]

I guess I didn't realize there were cowboys in New Zealand.

 

[gtb]

I'm missing some of the fired-up attendings that, in the past, would have valuable insight for this particular case.

As originally posted, with very low to unmeasurable SpO2, and a noninvasive blood pressure that just couldn't read. I wonder if anyone palpate a pulse? Did they try, or just rely on SpO2 and NIBP? There were some pretty interesting posts before mine, but I'll offer several of my own beliefs.

1. Hypoxia is a wonderful muscle relaxant. Every single individual I've intubated during a code has completely abducted cords.

2. When a patient is actively dying and very hypoxemic, I believe that wasting time while waiting for any hypnotics only diminishes odds of a successful resuscitation. It's not clear to me why the patient was not intubated prior to transport to the ICU, but I suspect I'm missing details on that decision. I genuinely am not concerned about recall for a patient who's millimeters from CV or respiratory collapse.

3. I believe in the case describe, with no room for error, that the most skilled airway person should make the first attempt at placing an endotracheal tube. The first attempt is, in my opinion, offers the cleanest airway and best opportunity to successfully place the ETT in the right spot.

I'll not comment on many of the previous posts except to say, that I greatly miss the temporarily (I hope) banned attendings, and that it reminds me that often people don't know what they don't know (The Dunning–Kruger effect).

 

[dhb]

I guess I didn't realize there were cowboys in New Zealand.

Sheepboys they're called sheepboys 😛

 

[Rotors]

Main takeaway so far: you know how to spell suxamethonium. We get it.

What, it's what it's called ...

And for the paralytic/no paralytic debate, I'm VERY hesitant to push sux for an emergent airway if nobody can give me history. If it's a matter of getting the airway vs not, I'll do it, but I don't routinely use paralytic at remote (floor, ICU) airways, unless I have an attending with me. Pushing sux in someone with unknown history scares me- especially someone who is septic, acidotic and maybe in ARF. That's just my take.

Interesting, by your name I will assume you're an Anaesthetic Registrar?

My take is if you're worried about malignant hyperthermia or hyperkalaemia, use vecuronium instead

We are probably more worried about sux in this setting then we should be, if no history of burn/spinal cord injury/etc then its probably safe.

I agree

I have added "super crook" to my peri-operative lexicon.

LOL awesome, you can also add "heaps nunngered" which is the traumatically injured super crook patient; see crook means sick whereas nunngered means broke; so if you're sick (i.e. sepsis or something) then you're crook but if you've got a massive flail chest with bilateral haemopneumothoracies then your're nunngered.

I don't know how EMS exists in NZ. Your condescending tone is duly noted, and you can stuff it. Paramedics in the US have protocols to follow (just like corpsmen/medics in the US military). I guess it's good for the paramedics if they don't have a doctor they can call for questions. As I don't know the education level, I can't say if it is good for patients.

I could care less if you find me condescending, I said you might find it interesting to see how something works outside of the US, but if you don't then no skin off my nose

To answer your question a Paramedic has a Bachelors Degree; an Intensive Care Paramedic has a Post-Graduate Diploma (2/3 of a Masters Degree) and it is the ICPs who have RSI

I guess I didn't realize there were cowboys in New Zealand.

I'm not sure how using routinely using anaesthesia and paralysis to tube people (including people who are critically unwell) makes for cowboy practice.

Sheepboys they're called sheepboys 😛

*facepalm

 

[jwk]

To answer your question a Paramedic has a Bachelors Degree; an Intensive Care Paramedic has a Post-Graduate Diploma (2/3 of a Masters Degree) and it is the ICPs who have RSI

I'm not sure how using routinely using anaesthesia and paralysis to tube people (including people who are critically unwell) makes for cowboy practice.

Big difference then in paramedic educational levels. Not knocking the medics here at all, but most EMS degrees are two-year associate degree programs. Sounds like a pretty apples to oranges comparison.

I think people are simply trying to make the point that sedation and/or paralysis are frequently unnecessary in many emergent intubations, and even when used appropriately are not without risk. Just as you're pointing out how things are done in NZ, we're letting you know how they're done here. Of course we think our way is better... 😉

 

[IlDestriero]

Sheepboys they're called sheepboys 😛

Please don't drive the new guy off, we could use more international perspective.👍

 

[dhb]

Nothing against him it was just in the context

 

[Lightwand]

Interesting, by your name I will assume you're an Anaesthetic Registrar?

My take is if you're worried about malignant hyperthermia or hyperkalaemia, use vecuronium instead

I'm a senior resident in Anesthesiology. I think that's the equivalent of what you're calling a registrar.

I'm not worried about MH. I am worried about hyperkalemia, particularly in the population we're talking about. I've seen a hyperkalemic sux arrest and it is quite impressive. In a patient who is acidotic, likely in ARF, hyperkalemia is a concern for me.

If I do use a paralyic, I use rocuronium. The main reason I avoid this at times is because of our patient population and seeing that MANY of our airways are unfavorable. If I had to guess, I'd say that our average patient weight is around 100-110kg. If it's an emergency and they need a tube NOW, pushing paralytic when I'm unsure that I'll be able to ventilate effectively won't do me any good. Besides that, you're adding a couple minutes of time until you put the tube in, if you wait for the paralytic to work. I'm not pushing high-dose roc to shorten the time to onset without another pair of well-experienced anesthesia hands or an attending with me.

I completely agree that paralysis will likely give you the best look. But the majority of these airways can be secured without paralytic. If it's truly an emergency, paralytic usually isn't needed, as gtb said. If the patient doesn't need drugs, I'm not going to use them.

Just my thoughts...

 

[proman]

I completely agree that paralysis will likely give you the best look. But the majority of these airways can be secured without paralytic. If it's truly an emergency, paralytic usually isn't needed, as gtb said. If the patient doesn't need drugs, I'm not going to use them.

Just my thoughts...

My approach as well.

 

[ketofol]

Great discussion. Having spent significant time in australia involved in "anaesthetics" at a medical student level it is a different environment and similar to the one Rotors depicts.

I am by no means claiming to be an authority on these topics but want to pass on some interesting articles that might inform the conversation more and have an international flare.

1) Check out this abstract "The Safety of Emergency Endotracheal Intubation Without the Use of a Paralytic Agent" 400 tubes with just propofol.
http://chestjournal.chestpubs.org/cgi/content/meeting_abstract/138/4_MeetingAbstracts/202A

2) Look at the exceptional blog EMCRIT topic on paralytics vs. no paralytics for intubation
http://emcrit.org/podcasts/paralytics-for-icu-intubations/

3) NAP 4 Trial from the UK which looked at complications of intubations.

http://resusme.em.extrememember.com/?p=4311

They advocated for continuos CO2 monitoring in all intubations in ED and ICU. Colorimetic CO2 detectors have serious limitations in Cardiac arrest, Acute PE, Hypothermia, Airway obstruction. The current european resus guidelines advocate for continuous CO2 monitoring (which also has serious limitations but more on that in another post)

Importantly the NAP 4 trial lead to the recommendation that all anesthesia providers learn to perform a surgical airway because perc cric kits failed 60% of the time.

Not trying to hijack just collecting some comments from other posts

 

[Idiopathic]

I'm missing some of the fired-up attendings that, in the past, would have valuable insight for this particular case.

As originally posted, with very low to unmeasurable SpO2, and a noninvasive blood pressure that just couldn't read. I wonder if anyone palpate a pulse? Did they try, or just rely on SpO2 and NIBP? There were some pretty interesting posts before mine, but I'll offer several of my own beliefs.

1. Hypoxia is a wonderful muscle relaxant. Every single individual I've intubated during a code has completely abducted cords.

2. When a patient is actively dying and very hypoxemic, I believe that wasting time while waiting for any hypnotics only diminishes odds of a successful resuscitation. It's not clear to me why the patient was not intubated prior to transport to the ICU, but I suspect I'm missing details on that decision. I genuinely am not concerned about recall for a patient who's millimeters from CV or respiratory collapse.

3. I believe in the case describe, with no room for error, that the most skilled airway person should make the first attempt at placing an endotracheal tube. The first attempt is, in my opinion, offers the cleanest airway and best opportunity to successfully place the ETT in the right spot.

I'll not comment on many of the previous posts except to say, that I greatly miss the temporarily (I hope) banned attendings, and that it reminds me that often people don't know what they don't know (The Dunning–Kruger effect).

i believe there has been insight offered (just in grammatically normal sentences, nonbolded, without 24pt font), including every point you just mentioned.