Fire during intubation

Discussion in 'Critical Care' started by Nephro critical care, Mar 2, 2017.

  1. SDN is made possible through member donations, sponsorships, and our volunteers. Learn about SDN's nonprofit mission.
  1. Nephro critical care

    Nephro critical care 2+ Year Member

    46
    40
    Feb 4, 2014
    So I have this patient with respiratory failure who I am preoxygenating with nasal cannula prior to RSI. I took the cannula off and intubated the patient and he developed ventricular fibrillation immediately afterwards. Code was called and the nurse shocked him. Patient came back to sinus rhythm with the shock but bang at the same time the patient's bedsheets caught fire. Nurses frantically tried to extinguish the fire and then I who was at the head of the bed picked up the sheets and shook them until the fire was extinguished. Turns out the nasal cannula were still on the bed blowing oxygen on the patient and the defibrillator paddles sparked a fire . No harm was done but I was thinking both the patient and me at the head of the bed would have easily been turned into blackened Jamaican Jerk chicken.

    Beware of nasal cannulas during defibrillation .
     
    Mad Jack, Meowgical, tartesos and 3 others like this.
  2. SDN Members don't see this ad. About the ads.
  3. FFP

    FFP Grunt/cog/body Gold Donor 7+ Year Member

    4,727
    3,476
    Oct 17, 2007
    Interesting. Worth a case report.
     
  4. BigRedBeta

    BigRedBeta Why am I in a handbasket? 7+ Year Member

    1,097
    288
    Nov 1, 2007
    Physician
    As my wife said "well that's...shocking"
    Sorry that's terrible. Have heard of issues like this in the OR, but never with NC flow. What was the flow rate?
     
  5. Nephro critical care

    Nephro critical care 2+ Year Member

    46
    40
    Feb 4, 2014
    It was 15 liters i.e maxed out . When the person was defibrillated a spark shot out from the paddles towards the cannula but the cannula being not flammable did not catch fire . But the bed sheets had some nylon mixed in so they did.
     
  6. drmwvr

    drmwvr 7+ Year Member

    289
    51
    Dec 2, 2008
    Unrelated comment here, but why take them off for intubation? Might give some advantage in prolonging apneic oxygenation.

    Back on topic, we've switched to adhesive pads for just such issues.
     
  7. Nephro critical care

    Nephro critical care 2+ Year Member

    46
    40
    Feb 4, 2014
    I tend to take the cannulas off when I start bagging . The cannulas prevent a good seal . Some of this is probably dogma ground into me from training. My standard intubation RSI procedure in ICU is preoxygenate with cannulas ( which doesn't necessarily bring up sats in ARDS unless using bipap ) . Then give 2 mg of versed and then etomidate (0.4 mg / kg ) . After etomidate usually pt will tolerate oral airway . Then bag up rapidly to sats 95% or greater ad make sure they can be bagged. Bag for 2 -3 minutes but if you bag too long then pt's stomach will fill up with air and there is risk for vomiting. Then succinylcholine ( or roc if hyperkalemia or contraindications to sux ) and then tube 1 minute later. Works like a charm .

    Follow with propofol gtt and keep Levophed ready. If vent dysynchrony in 1st hour give rocuronium 1 dose after additional Versed, fentanyl , propofol . Invest in A -line at 1st sign of hypotension. 1st hour after intubation and rocuronium is golden time for procedures like central line , Aline and bronchoscopy.
     
    tartesos likes this.
  8. tartesos

    tartesos Medalaganario Gold Donor 5+ Year Member


    Neat layout.
    Doesn't sound too rapid to me.

    And you forgot the #notmedicaladvice.



    Sent from my iPhone using SDN mobile app
     
  9. tartesos

    tartesos Medalaganario Gold Donor 5+ Year Member

    At least a poster!


    Sent from my iPhone using SDN mobile app
     
  10. Nephro critical care

    Nephro critical care 2+ Year Member

    46
    40
    Feb 4, 2014
    It's not that rapid but I feel 5 minutes of preparation/ preoxygenation / or bagging to sats > 95 % is worth it if you can get an extra 3 minutes while you are getting the tube in on the 1st attempt. Invariably happens that if pts sats are 89 - 90% at the time of intubation attempt I will fumble with the glidoscope stylet in the back of the oropharynx and then nurse will inform me sats are 80% and I will have to pull out and restart bagging. And once you have given NMB it becomes harder to get sats up with bagging. By then I am getting Prinzematal's angina and it's not a nice feeling.
     
  11. SurfingDoctor

    SurfingDoctor "Hooray, I'm useful" 10+ Year Member

  12. Nephro critical care

    Nephro critical care 2+ Year Member

    46
    40
    Feb 4, 2014
    That's indeed true . I have had a good experience intubating ARDS / high oxygen requirements with 100% high flow at 60 L / min. Sats remained 90% despite not being an easy airway. Only problem is the cost as our hospital RT department would get upset if we used an Optiflow device just for intubation because it would be wasted afterwards.

    Also the fire that would have occurred with high flow oxygen from defibrillator paddles would be interesting . Probably the fire department would have to come to put it out.
     
  13. OTCAwesome

    OTCAwesome

    28
    51
    May 28, 2015
    Cold
    In a true RSI you shouldn't be bagging the patient. Also after giving a paralytic, it should be easier to bag the patient, not harder
     
  14. Nephro critical care

    Nephro critical care 2+ Year Member

    46
    40
    Feb 4, 2014
    I guess my technique would be defined as a ' modified ' RSI intubation. ICU intubations are different from ED intubations in that usually the patient has been sick for some time so less likely to have a full stomach. That is unless they were getting tube feeds. They are also going to be more hypoxic so you will have less time to get the tube in so better have sats 99 % prior to 1st attempt.

    To me at least the big fat dudes become harder to bag once I give the sux. Their oropharynx just collapses .
     
  15. chocomorsel

    chocomorsel Senior Member 10+ Year Member

    Maybe you are spending all your energy bagging a non paralyzed patient that by the time you are bagging them and they are relaxed, you muscles are fatigued. With proper technique, relaxant almost always helps with mask/bag ventilation.

    Also, with patients who are septic, sick ice, etc, they may not have per se a "full stomach" worth of food, but what about delayed gastric emptying and higher content of stomach acids, illeus than healthy patients? If you make a decision to RSI a patient, especially a septic patent (GI induced especially) put that pressure on the cricoid and go for the tube as soon as he/she defasciculates. Been there, done that, a whole bunch of green **** spewed out into the airway.
     
    OTCAwesome likes this.
  16. tartesos

    tartesos Medalaganario Gold Donor 5+ Year Member


    True that with the back up. If it catches you by surprise( vomit or blood), you can always intubate the esophagus with an ETT and put it to the side of the mouth towards the staff you dislike the most( :banana:), and have them hold the suction to it, it looks cool. and lets you keep the area clean and see better( Do not attempt this with a glidescope), no need to inflate the balloon but if you do remember to deflate on once you pass the cords....
     
  17. tartesos

    tartesos Medalaganario Gold Donor 5+ Year Member

    This works great. As a rule, if someone is on HFNC, do not ever take them off to intubate as I`ve seen some people do, max the flow and go straight to tubing, no need to bag, and you can bag on top of it if need be( not the best seal but....)
    #notmedicaladvice
     
    WheezyBaby and SurfingDoctor like this.
  18. turkeyjerky

    turkeyjerky 7+ Year Member

    1,656
    49
    Sep 27, 2008
    Physician
    I really hate to derail the thread and apologize, but your technique is not even close to being RSI, modified or not, and you'll confuse yourself and others if you refer to it as such. Please just call it an intubation (using a suboptimal method for proxy gentian, sedation and paralysis...sorry)
     
    tartesos and Hamhock like this.
  19. Nephro critical care

    Nephro critical care 2+ Year Member

    46
    40
    Feb 4, 2014
    HFNC helps especially as a pre-oxygenator on steroids . Our hospitals issue with HFNC is that the Airflow / Optiflow cannula is not cheap so our hospital gives us crap if we are using it for a short time just to preoxygenate prior to intubation. But it works great as a preoxygenator I have had a recent IPF with really s''''' sats who I preoxygenated and then they didn't desat while I took time to look during intubation. It won't help though if you fail on your intubation attempt and then desat only good bagging will bail you out at that point.

    What's wrong about bagging ? it's what will save you if you fail to intubate . I have done 500 ICU intubations with maybe 5 fails where I needed to call anesthesia . I never learnt how to LMA . And yet I have never had trouble with desating because I could always bag them with a jaw thrust .
     
  20. psychbender

    psychbender Cynical Member 10+ Year Member

    There's nothing wrong with manually ventilating they patient. The problem is doing so and calling it "rapid sequence." RSI is push induction drugs, sux or high - dose roc, tube seconds later. Slowly working in induction drugs, using lower doses of relaxants, ventilating the patient while giving everything time to work is not rapid, but may be the best thing for the patient, depending on the clinical situation. My only gripe with your technique is that you use a lot of etomidate when it may not be necessary to use any at all, or only a tiny bit is needed (if I use it, I'll typically only give 0.1mg/kg in the critically ill). But, if it works, it works.

    Sent from my SM-G930V using SDN mobile
     
    OTCAwesome likes this.
  21. Hamhock

    Hamhock 7+ Year Member

    869
    81
    May 6, 2009
    Wow.
    Who taught you airway management? (which is very different than "intubation")

    It's a matter of time, my friend...

    HH
     
    OTCAwesome likes this.
  22. Nephro critical care

    Nephro critical care 2+ Year Member

    46
    40
    Feb 4, 2014
    I guess the LMA is a good skill to learn. Unfortunately though for CC sometimes it's a hard skill to learn if you don't do it as ICU pts unlike OR pts get tubed every time never LMA . Sometimes in a pinch it's hard to get an LMA in so I just focused on good bag / mask skills . Maybe that's also fellowship training which has carried on. We would call anesthesia if expected difficult airway and sometimes they used an intubating LMA . If we were responsible and anesthesia weren't available and SHTF we would slash / cric. All fellows got a couple of crics that way . Maybe that's not right but that's the way we did it.

    I haven't had that happen as an attending though. I have learnt to assess airway well prior to intubation and call anesthesia if I anticipate it's difficult which is probably 5 -10 % of the time . I ask anesthesia to let me try with them around and sometimes they comply but mostly they have a CRNA who wants 1st dibs and they let their CRNA do it. I have seen CRNAs mess up the intubation very badly too CRNAs should not do ICU intubation. They shove the tubes in with so much force and cause airway trauma and make it tough for the anesthesia attending as well.
     
    Last edited: Mar 30, 2017
  23. DrSnips

    DrSnips Hospitalist 5+ Year Member

    411
    230
    Apr 18, 2012
    Physician
    Case report? This is worth a RCT. You need one arm getting shocked with the nasal cannula, one arm shocked without it and then a control arm that starts off on fire.
     
  24. Nephro critical care

    Nephro critical care 2+ Year Member

    46
    40
    Feb 4, 2014
    Nothing to snicker about . Everyone has an personal adverse event they learn from and maybe report / blog so that others don't make the same mistake. It's easy to forget nasal cannulas when you have an unexpected cardiac arrest during an intubation.
     
    alternatego and FFP like this.
  25. shoal007

    shoal007 2+ Year Member

    164
    105
    Nov 15, 2013
    this is a modified delayed sequence intubation. but none the less i wouldnt recommend it. Youre going to get aspiration at some point and a horrible airway. bipap them if theyre awake to get their sats up then rsi.

    just imho. good luck

    Sent from my Pixel using Tapatalk
     
  26. Nephro critical care

    Nephro critical care 2+ Year Member

    46
    40
    Feb 4, 2014
    Yeah I have changed my practice a little bit and am now doing more a straight RSI. Some of this modified delayed SI was fellowship learned dogma. Many attendings have a different way of doing things and pass it on to their fellows. When you get on into the real world you learn new ways of how the rest of the world does things .
     
    AdmiralChz likes this.
  27. Random Anesthesiologist

    Random Anesthesiologist Random Anesthesiologist Gold Donor 7+ Year Member

    1,538
    290
    Mar 16, 2008
    You're either doing an RSI, or you're not. This modified rsi business is not rsi. If your patient can tolerate a nasal cannula, they can tolerate true preoxygenation with a bag-mask and a seal and allowing them to spontaneously breathe with assistance. If my resident ever tried to intubate in the unit or in the OR the way you did, there would be a very long discussion at the very least and probably having them present at M&M. Find an anesthesiologist and follow them. Make them teach you the correct way to manage an airway, including an LMA. If you are going to be intubating anyone in your career, you'd better know the difficult airway algorithm and how to implement the steps. You don't usually have time in a can't-ventilate can't-intubate situation to wait for backup.


    Sent from my iPad using Tapatalk
     

Share This Page