GCS and the need for induction dose for intubation?

[ketap]

hello, i am really curious about this:
1. if there is a patient with a decreased level of consciousness, how can i know if for intubation this patient still needs the induction agent (or even a fentanyl, lidocain) or not ? is it possible if we correlate it with GCS level?

2. Can i know it by checking the absence of eyelid reflex?
and

3. is it possible that a patient needs only some response blunting drug (such as fentanyl or lidocaine iv) without the need of induction agent? thx u

please help answer..sorry for asking lots of questions..i am quiet confuse about this..

warm regards, Ketap

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[RustedFox]

No matter what the GCS; you don't want them to suddenly wake up during RSI. Bronchospasm is also a pain in the keister. I learned that once I thought that "this guy won't need paralytics".

Induce and paralyze for all in my book, regardless of GCS. I may use different agents for different situations, but everyone gets put down and paralyzed.

 

[dchristismi]

Part of it is learning process and being comfortable with airway management. I will often just intubate without RSI if the pt is obtunded enough/arresting/etc. When in doubt, RSI. Your induction agent is for the benefit of the patient - it's not something you really want your patient to be aware of.

In an initially conscious patient, I almost always use paralytics, with the rare exception being a difficult airway situation where I do not want to provoke a cannot-intubate-cannot-ventilate situation. I had one recently - a horrible angioedema in a guy with a fat, short neck whose tongue was swollen out of his mouth. We wanted to see if we could secure airway without paralytics, but my nurse had the sux ready in case we ran into laryngospasm.

 

[RustedFox]

D - Curious about your case. What ultimately ended up happening to short, fat, no-neck guy ?
Did you get the tube without much difficulty ?

To the OP: I should also add that while succinylcholine is my general agent of choice... if you push succ too fast then you can run into bruxism (seen it), which defeats the purpose anyways.

In this month's EM Annals, there's a really cool article by Weingart about using CPAP during preoxygenation. He also states that rocuronium may be ideal in difficult situations, as it seems that it gives you a "longer time to desat" metric. I'm-a gonna start using it.

 

[dchristismi]

Glidescope FTW. Just etomidate, because we knew that bagging him would be a challenge, and he was maintaining his sats. Would have been candidate for an awake... if it weren't 2 am. Could barely get the glidescope around his tongue, and took several tries to position the tube, but got it. We had the sux, but ultimately didn't need it. A little squirt of hurricane spray also helped.

Definitely sphincter-tightening, and had all our other toys ready. Probably would have tried to pass a bougie under glidescope visualization and then the tube over it. This was an unusual case, though, since it was impending airway obstruction rather than a pulmonary etiology.

 

[ketap]

thx u for the answers, RustedFox and dchristismi..i really appreciated it..but i need to ask you also some questions again if u don't mind..

I will often just intubate without RSI if the pt is obtunded enough/arresting/etc.

1. actually that is what i am asking...how can i know that the patient has obtunded enough to be intubated without any drugs especially the induction drugs?

2. btw, if he was obtunded enough, should i still give the fentanyl or lidocaine to blunt the sympathetic response from laryngoscope for the patient?

3.if u have an unconscious person and u give the induction ...how can i measure if the induction is enough (as the patient has already loss of consciousness before)?

thx u so much..i am sorry because i am asking more question, because i am still quiet confuse about this..

 

[EM_Rebuilder]

thx u for the answers, RustedFox and dchristismi..i really appreciated it..but i need to ask you also some questions again if u don't mind..



1. actually that is what i am asking...how can i know that the patient has obtunded enough to be intubated without any drugs especially the induction drugs?

2. btw, if he was obtunded enough, should i still give the fentanyl or lidocaine to blunt the sympathetic response from laryngoscope for the patient?

3.if u have an unconscious person and u give the induction ...how can i measure if the induction is enough (as the patient has already loss of consciousness before)?

thx u so much..i am sorry because i am asking more question, because i am still quiet confuse about this..

If its a code situation, no drugs are needed.. just intubate and do what you can.

As far as "obtunded enough"... If there are zero reflexes (no gag, no corneal, etc) you could make a go without any drugs. Personally, if the patient is that low on the scale, I still tend to give a slug of paralytic... I tend to NOT give a sedative (etomidate, versed, etc) as if the patient is 'obtunded' they are sedated enough already in my book and you just end up dropping their pressures, etc.

Lidocaine for head bleeds and such... as I understand, its a bit controversial. I personally learned to give it while in residency (where there was a NSG program and they always wanted it) so I still give it anytime I suspect a bleed. I do not think there are many negatives to giving it.. so if you have the time, give it.

 

[southerndoc]

If the patient has a gag reflex, they get paralytics. If they're obtunded enough to have no gag reflex, I still give them etomidate. There is evidence obtunded patients may still feel pain and remember it, so that's why I use it.

About the only time I don't RSI is when they're in cardiac arrest. I don't use paralytics initially on difficult airways (will induce and take a look, then paralyze if necessary if I can visualize the cords).

 

[tkim]

I still RSI. Got called to the floor to tube a resp failure with thick nasty secretions. I asked for RSI, and the pulmonologist in the room said 'He's pretty obtunded, I don't think you need RSI - do you?"

So I brutaned the tube, the patient did one of those deep "I just got intubated" coughs and brown schmutz shot out of the tube and onto the pulmonologist's sleeve. Now when I asked for RSI meds, she says nothing and takes two steps back.

 

[southerndoc]

I still RSI. Got called to the floor to tube a resp failure with thick nasty secretions. I asked for RSI, and the pulmonologist in the room said 'He's pretty obtunded, I don't think you need RSI - do you?"

So I brutaned the tube, the patient did one of those deep "I just got intubated" coughs and brown schmutz shot out of the tube and onto the pulmonologist's sleeve. Now when I asked for RSI meds, she says nothing and takes two steps back.

Your pulmonologists can't intubate? Interesting.

 

[Hamhock]

Your pulmonologists can't intubate? Interesting.

Many can't.

Many more shouldn't.

The range of skills and knowledge about acute airway management (actually all of emergent resus) of pulm/CCM docs still amazes me....and it is not just the "some docs are good, some suck" spectrum. It is a result of dramatically different training programs, from what I have seen.

As much as I like to point out in this forum that not all EM residencies train docs equally well, the spectrum is shockingly bigger for pulm/CCM training.

To provide a sense of one end: The last hospital I worked at, all MICU and SICU tubes were paged overhead for anesthesia...not a single ETT was placed by the MICU fellows or MICU attendings...and the management of the airway before the arrival of anesthesia was often NRB or ineffective BVM.

[[Before people start asking how many programs I could actually be familiar with vs. how many exist: yes, I admit I am basing my comments above on direct exposure to about 10-12 hospitals and only on informal/indirect knowledge of barely double or triple that...but I am still shocked by the variety.]]

HH

 

[ORL10]

same experience at our shop, either off service ER residents do the tube in the ICU (they cannot however use paralytics on the floors unless the ICU doc gives consent), or anesthesia has to come and do the tube. Good learning I guess for interns in the unit, but this came as a surprise to me as well.

I have yet to see a pulm/CC doc call for RSI and intubate a patient, even when the patient is peri-code.

 

[tkim]

Your pulmonologists can't intubate? Interesting.

Ours can, but she got there after I did.

 

[Apollyon]

When I was prelim IM at Elmhurst, there was a code one day, and the protocol was the ICU resident would respond, to intubate, along with the primary team. I, as the intern, intubated the patient, and my senior was calling the drugs, and the ICU resident was...Scott Weingart! And he said right then that "I could work with you any day". However, that did not transfer into an EM spot at Mt. Sinai.

 

[pinipig523]

When I was prelim IM at Elmhurst, there was a code one day, and the protocol was the ICU resident would respond, to intubate, along with the primary team. I, as the intern, intubated the patient, and my senior was calling the drugs, and the ICU resident was...Scott Weingart! And he said right then that "I could work with you any day". However, that did not transfer into an EM spot at Mt. Sinai.

Cool story... Weingart is our guest lecturer in a few weeks at our home institution.

 

[alphaholic06]

When I was prelim IM at Elmhurst, there was a code one day, and the protocol was the ICU resident would respond, to intubate, along with the primary team. I, as the intern, intubated the patient, and my senior was calling the drugs, and the ICU resident was...Scott Weingart! And he said right then that "I could work with you any day". However, that did not transfer into an EM spot at Mt. Sinai.

Great story!!!!

 

[ketap]

thx u all for the answers..i get it now...

btw, can i use the eyelid reflex also to predict that the patient is obtunded enough? thx u

 

[RustedFox]

I wouldn't base anything off of just an eyelid reflex.

 

[ketap]

thank u, Rusted Fox i have seen it clearer now..

lots of valuable information i have got in here..

best regards,

Ketap