Floor intubations

[Varmit22]

How does everyone feel about what drugs to use for an emergency intubation on the unit. I've talked to some who would never give succ, and only give etomodate. Other thoughts?

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[jetproppilot]

How does everyone feel about what drugs to use for an emergency intubation on the unit. I've talked to some who would never give succ, and only give etomodate. Other thoughts?

Great, salient topic that I've posted about at length previously.

And my opinion goes against the grain.

I always give muscle relaxant unless contraindicated, with the belief that 20-40 mg sux will optimize your view, giving you the best chance of getting the tube in.

If it doesnt go well, such a small dose will wear off quickly and the patient will start breathing again pretty quickly.

For more info, and access to more lengthy posts, please search the archives.

 

[Arch Guillotti]

http://forums.studentdoctor.net/showthread.php?t=226462&highlight=floor+intubation

Recent thread.

 

[numbmd]

I always try to individualize treatment to my patients. Etomidate is very good, sux is another drug you want in your bag, but sometimes brutane is the only way to go. Depends.

 

[cchoukal]

My attendings seem to fall into two camps: make your first shot your best by anesthetizing and paralizing, versus, do nothing that you can get blamed for later (topicalized awake DL). Honestly, both seem to have their place. Many of my floor intubations are for failing pulmonary cripples in the MICU. They're usually so tired/narcosed/distressed, that the awake DL is pretty easy.

I've often wondered what the ethics/efficacy is of just giving succ to these people. You could argue it wouldn't compromise their hemodynamics like an induction agent, would give you the same view, and they'd be really unlikely to have recall anyway, since they're so compromised.

 

[Tenesma]

Don't use muscle relaxants on the floor - uncontrolled environment with people there only to trip you up instead of help you...

Tell the patient it is going to be very uncomfortable
Spray the crap out of their throat with benzocaine
get a Miller 2
get a few RNs to hold the patient down
As soon as the tube goes in let them give a dose of ativan and morphine and deal with the hemodynamic consequences

but 90% of intubations will be on patients who don't care enough to put up a fight...

 

[oudoc08]

Don't use muscle relaxants on the floor - uncontrolled environment with people there only to trip you up instead of help you...

Tell the patient it is going to be very uncomfortable
Spray the crap out of their throat with benzocaine
get a Miller 2
get a few RNs to hold the patient down
As soon as the tube goes in let them give a dose of ativan and morphine and deal with the hemodynamic consequences

but 90% of intubations will be on patients who don't care enough to put up a fight...

Why no benzo pre-tube? Seems like it would smooth it out, and a hella lot more comfortable (for the pt, that is).

A little (lot) of versed was how we did it back in my bamblance days.
Hemodynamics? Hell, you got a line, they're already on the floor.

We used sux and norcuron too, but I can see the argument w/ that.

 

[Gern Blansten]

Blind nasal works about 90% of the time in a tired, but spontaneously breathing patient if done correctly.

 

[rsgillmd]

Why no benzo pre-tube? Seems like it would smooth it out, and a hella lot more comfortable (for the pt, that is).

A little (lot) of versed was how we did it back in my bamblance days.
Hemodynamics? Hell, you got a line, they're already on the floor.

We used sux and norcuron too, but I can see the argument w/ that.

In my experience, Versed sucks. It may make them not remember, but it does not smooth anything out. If I give any induction agent, it is usually Etomidate, occasionally Propofol.

I find I can do 99% of my intubations without Sux. But I have used it on occasion to get past the cords of the people who are breathing so fast, you have to be Superman to slip the tube in between breaths. I suppose a bougie would be easier to slip in those cases, but never tried it. 20-40 mg (usually 20 mg) Sux is enough to weaken them to allow me to pass the tube.

Like numbmd said, you have to individualize it to the patient.

I never tried topicalizing on the floor. I'll have to keep it in my bag of tricks.

Ravpreet

 

[rsgillmd]

Only other thing to add about not paralyzing is it helps when you are not the one doing the DL -- ex: ICU fellow wants to try.

I learned that after having a bunch of "I see the cords" comments, and the tube still ends up in the esophagus.

Now I just say to them, "Look for the moving vocal cords. If you don't see a structure that is opening and closing, you probably aren't looking at the cords."

 

[Jeff05]

i reserve the brutane approach for codes or for those hanging on by a thread (hemodynamically not tolerate even 10 of etomidate). i believe paralytics allow one to optimize the view and decrease potential airway trauma resulting from laryngoscopy of a struggling patient. sedation should be considered as a standard, in my opinion.

unless succ is contraindicated, i usually push etomidate 10mg/lidocaine 1mg/kg/succ 20-40mg - all premixed in one syringe. if the pt is very hypertensive i may replace the etomidate with 50mg of prop.
on average, i have perfect intubating conditions within 60 seconds. spontaneous respiration returns within 3 min.

 

[VentdependenT]

Blind nasal works about 90% of the time in a tired, but spontaneously breathing patient if done correctly.

Never done it. I'm intrigued however.

However I usually dont have time to ask about a patients INR during a code. Lots of these old timers are on coumadin. Or Plavix.

I know airway comes before epistaxis, but a botched nasal can lead to one hell of a nose bleed in these folks. Not that I care about the nose bleed, its just that it can seriously complicate your ability to view the airway.

 

[Gern Blansten]

Never done it. I'm intrigued however.

However I usually dont have time to ask about a patients INR during a code. Lots of these old timers are on coumadin. Or Plavix.

I know airway comes before epistaxis, but a botched nasal can lead to one hell of a nose bleed in these folks. Not that I care about the nose bleed, its just that it can seriously complicate your ability to view the airway.

I don't use it during codes. Only in spontaneously breathing people and if you have a couple of minutes to prepare. The nosebleed deal is a big problem, but I usually have time to inquire about their coagulation status from one of the primary team that is usually there. If they are having an MI or a PE, I avoid it because they will probably need anticoagulation very soon. Works well for the old COPDer who is getting tired and needs help with ventilation. Tips that have helped me are using lidocaine ointment coated nasal trumpets to dilate and anesthetize prior to ETT placement. Then place the ETT and listen at the tip for optimal breath sounds as you advance(ie, if the breath sounds through the ETT become more faint, pull back until they are the strongest. Then time your quick advance with an inspiration. It is usually pretty easy to tell if you are in. If they are saying "Ouch!" you probably aren't in. If there are coughing breaths and sputum flying from the ETT, you are probably in. Sometimes it takes a couple of passes.
As vent mentioned, bleeding can be an issue. If you are thinking fiberoptic intubation is a probable next step, I would avoid this technique so that the airway isn't bloodied up.

 

[oudoc08]

Then place the ETT and listen at the tip for optimal breath sounds as you advance(ie, if the breath sounds through the ETT become more faint, pull back until they are the strongest. Then time your quick advance with an inspiration.

Nothing like being perched over the patient, one ear to the nasal ETT, advancing... hearing breath sounds through the tube... a cough, and a nice wet willy.

 

[Lefty]

How often are you (anyone) using blind nasals? Are you using a nasal rae? Endotrol? Under what conditions do you prefer to use them in?

Lefty

 

[militarymd]

I always try to individualize treatment to my patients. Etomidate is very good, sux is another drug you want in your bag, but sometimes brutane is the only way to go. Depends.

don't like etomidate.....there is an association between its use and overall increase in morbidity in the critically ill......

 

[militarymd]

How often are you (anyone) using blind nasals? Are you using a nasal rae? Endotrol? Under what conditions do you prefer to use them in?

Lefty

don't like nasal tubes....there is an association between nasal tubes and VAP.

 

[Gern Blansten]

How often are you (anyone) using blind nasals? Are you using a nasal rae? Endotrol? Under what conditions do you prefer to use them in?

Lefty

I don't use them very often, but it is a nice trick to know when you are alone in a tough spot. I use just a regular tube. Agree with mil about the VAP association when left in place for longer periods.

 

[powermd]

don't like etomidate.....there is an association between its use and overall increase in morbidity in the critically ill......

So what do you use in the critically ill?

 

[militarymd]

So what do you use in the critically ill?

same stuff that you would otherwise use to sedate them.

the act of intubating someone is not nearly as "stressful" as most people think it is...yes it is unpleasnat....but it is not nearly as stressful as suffocating to death because you can't move enough air into and out of your lungs because of some pathology.

stuff that I use in no particular order:

versed
ativan
propofol
morphine

I was asked to tube a COPD'er today....he was kind of robust....ie saturating fine...and CO2 not too high...but when you look at him, he's definiting working hard to breath...

8 of versed iv....DL ...saw cords, but he held his breath and I couldn't pass the tube...
so 20 mg of sux....after masking him for a little...then passed the tube.

Had a couple of hottie ICU nurses helping me..no residents.

 

[numbmd]

Wow, a single dose of etomidate gives a decreased outcome? I didn't know. Are you sure it's decreased outcomes is from sedation over long periods?
Do you avoid it in the OR?
Actually, for me, I think that the reason I use it sometimes is because it is not controlled, and I can keep it in my pocket. That and the smooth hemodynamics. I hate staying there for a while, having to deal with the outcome of hypotension after intubation. Trying to explain the change on physiology after controlled ventilation to a surgeon is like trying to teach my three year old chess.

Have done a few blind nasals as well, but projectile mucus is the main reason
I don't use it more.

Floor intubations is actually one of my favorite aspects of anesthesiology.

 

[VentdependenT]

After all the talk on this board, I personally see no role for etomidate anymore.

I used it once on a code in the unit as a CA-1 with my uppers. 8mg. Dude wen't into PEA (he was puffen away before hand, but he was coherent, could speak in 3-4 word sentences).

Not that it was etomidate intrinsically that caused his arrest (we got him back) but its not as benign as people make it out to be.

THere are many many other ways to have a hemodynamically stable induction/sedation than etomidate.

 

[militarymd]

Wow, a single dose of etomidate gives a decreased outcome? I didn't know. Are you sure it's decreased outcomes is from sedation over long periods?
Do you avoid it in the OR?
Actually, for me, I think that the reason I use it sometimes is because it is not controlled, and I can keep it in my pocket. That and the smooth hemodynamics. I hate staying there for a while, having to deal with the outcome of hypotension after intubation. Trying to explain the change on physiology after controlled ventilation to a surgeon is like trying to teach my three year old chess.

Have done a few blind nasals as well, but projectile mucus is the main reason
I don't use it more.

Floor intubations is actually one of my favorite aspects of anesthesiology.

It's published somewhere....it is not grade A evidence, but I just don't see a need for it.

In the past, it was studied for head trauma???....everyone in the etomidate arm died....from propylene glycol toxicity??

 

[gasnewby]

After all the talk on this board, I personally see no role for etomidate anymore.

we use it for most unstable trauma patients. (i think)-> decreases icp and minimal CV effects

 

[jetproppilot]

Never done it. I'm intrigued however.

However I usually dont have time to ask about a patients INR during a code. Lots of these old timers are on coumadin. Or Plavix.

I know airway comes before epistaxis, but a botched nasal can lead to one hell of a nose bleed in these folks. Not that I care about the nose bleed, its just that it can seriously complicate your ability to view the airway.

Older generation anesthesiologists used to use this alot more than we do. We've got a cool 69 year old dude....works a cuppla days a month... that can snake those blind nasals in likkity split.

I wish I knew how to do blind nasals. I was never taught them, so never practiced them; as a result I suck at them so never use the technique.

 

[VentdependenT]

we use it for most unstable trauma patients. (i think)-> decreases icp and minimal CV effects

You can use ketamine in these situations. Which would be my choice. Does ketamine increase ICP. I don't think so. Reasons to avoid it in neurologic procedrues are perhaps related to increased CMRO2. However, even this isn't clinically significant (I don't believe so) when using a volatile anesthetic.

http://www.anesthesia-analgesia.org/cgi/content/full/101/2/524

Interesting review of our little NMDA antagonist.

 

[gasnewby]

thanks for posting that. found one sentence in a review book that although ketamine normally stimulates the CV system, it may be a cardiodepressant in hypovolemic pts. didn't find too much more to support that though, in my brief search.

 

[VentdependenT]

all induction agents are cardiodepressants (except perhaps fentanyl which will cause bradycardia and versed which can do the same...however when combined physiologically unstable people can eat $hit BIG TIME on these drugs).

Ketamine will bottom someone out when their physiologically tapped out (hypovolemic should would definitely be one of those situations) and their catecholamines are depleted.

 

[Arch Guillotti]

Bump for the poster in the other thread that was wondering about sux on the floor.

 

[Pooh & Annie]

Thanks Arch

 

[Pooh & Annie]

all induction agents are cardiodepressants (except perhaps fentanyl which will cause bradycardia and versed which can do the same...however when combined physiologically unstable people can eat $hit BIG TIME on these drugs).

Ketamine will bottom someone out when their physiologically tapped out (hypovolemic should would definitely be one of those situations) and their catecholamines are depleted.

Isn't major hemorrhage/severe hypovolemia one of the situations where Ketamine is one ofthe better agents??

 

[Jeff05]

unless the patient has a clearly difficult airway, tubing him/her awake is BARBARIC. we are trained to put people to sleep/paralyze them and intubate them. use your training.

etomidate 10-14mg. or prop 50. or lido 100mg. and 20-40 of succ.
you wanna make your first attempt best. a struggling bucking patient is a setup for airway injury, laryngospasm, vomiting/aspiration.