input in intubating this patient

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Painter1

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i'm a physician who works in the e.r. and wanted your opinions on intubating the following patient.

patient presented to the e.r., hx of renal failure on dialysis, cad, htn. patient brought in by EMS after significant fall which by mechanism required activation of trauma team.

patient with hypoxia on non-rebeather at 15 liters, cxr was read as bilateral pna versus edema.

decision is made to intubate to facilatate further trauma w/u and protect airway.

patient remains with sat of 86-87% while getting bagged by respiratory with good seal.

to note, the patient is morbidly obese, c-collar in place but removed with person holding c-spine immobilzation.

do you go with RSI?

do you sedate only with etomidate for example and take a look?

i was concerned about paralyzing the patient with an already low o2 sat who was morbidly obese. any thoughts?
 
It's an interesting question. What would I do? Well, I'm a board certified anesthesiologist and what I would do might not be the best for you to do. You work in the ER, are you a board certified ER doc or IM or FP working in an ER? The best answer is that it depends how experienced with airway management you are.

Does the patient appear to be an easy intubation? Even with a c-collar, can they open their mouth wide? Any teeth in the way? Are they successfully assisting respirations with positive pressure suggesting the patient should be ventilatable?

Before giving sux in an HD patient, I'd be sure to check that potassium.



If it was me doing it, I'd probably just give a small dose of IV induction agent and use glidescope to throw the tube in without giving NMB.
 
tough call. my vote, as a board-eligible 🙂xf🙂 anesthesiologist is to perform RSI, paralyze and use video laryngoscopy/glidescope (if you have it) or direct laryngoscopy with inline stabilization. backup plan is mask ventilation followed by surgical airway. i would have someone who knows how to use a knife nearby.

my reasoning is that i dont think allowing the sedative to wear off is a realistic option, and if you sedate this patient even a little, you will need to ultimately secure the airway

this is the classic double-edged sword (except also give him asthma, critical aortic stenosis and a 8.5cm AAA) and effective treatment will obviously depend upon the things that Mman mentioned like oral opening, tongue size, teeth in place. i will say that if you are successfully mask ventilating this patient, then that is a good sign, although i would imagine it is more mask-support.

as an addendum, ive tried the whole "sedation with etomidate and take a look" approach several times and never felt satisfied. ive pretty much abandoned this technique.
 
tough call. my vote, as a board-eligible 🙂xf🙂 anesthesiologist is to perform RSI, paralyze and use video laryngoscopy/glidescope (if you have it) or direct laryngoscopy with inline stabilization. backup plan is mask ventilation followed by surgical airway. i would have someone who knows how to use a knife nearby.

my reasoning is that i dont think allowing the sedative to wear off is a realistic option, and if you sedate this patient even a little, you will need to ultimately secure the airway

this is the classic double-edged sword (except also give him asthma, critical aortic stenosis and a 8.5cm AAA) and effective treatment will obviously depend upon the things that Mman mentioned like oral opening, tongue size, teeth in place. i will say that if you are successfully mask ventilating this patient, then that is a good sign, although i would imagine it is more mask-support.

as an addendum, ive tried the whole "sedation with etomidate and take a look" approach several times and never felt satisfied. ive pretty much abandoned this technique.

I've rarely met a patient I can't intubate without paralytics while using a glidescope. I just need them out of it enough to hold still and not actively bite the handle, the rest is usually easy.

If I'm worried about them not spontaneously ventilating after I push the IV drug, I'll use ketamine and not etomidate.
 
thanks so far for the replies. i'd be happy to keep hearing others feedback/input.

i opted to use only etomidate with use of glidescope.

i went this route because in the past i had a similar case where after inducing and paralyzing a similar patient, the already low 02 sats plummeted and the patient proofed difficult to bag and intubate. in that case, i ended up using an LMA.

for this case, things started well, patient was nice and sedated after etomidate, able to see cords with glidescope, passed et tube, but then the patient was impossible to bag. it was like pressing your hand through a rock when trying to bag. turns out, the patient appears to have had a masseter spasm and was clenched down on the et tube.

placed nasal trumpet bilaterally, gave rocuronium, teased the et tube out, bagged through the nasal trumpets, was then able to re-intubate again with glidescope.

I'm thinking of maybe using versed without paralytic next time instead of etomidate without paralytic in similar case. read aboue documented cases of masseter spasm with etomidate. my luck.

anyone else?
 
thanks so far for the replies. i'd be happy to keep hearing others feedback/input.

i opted to use only etomidate with use of glidescope.

i went this route because in the past i had a similar case where after inducing and paralyzing a similar patient, the already low 02 sats plummeted and the patient proofed difficult to bag and intubate. in that case, i ended up using an LMA.

for this case, things started well, patient was nice and sedated after etomidate, able to see cords with glidescope, passed et tube, but then the patient was impossible to bag. it was like pressing your hand through a rock when trying to bag. turns out, the patient appears to have had a masseter spasm and was clenched down on the et tube.

placed nasal trumpet bilaterally, gave rocuronium, teased the et tube out, bagged through the nasal trumpets, was then able to re-intubate again with glidescope.

I'm thinking of maybe using versed without paralytic next time instead of etomidate without paralytic in similar case. read aboue documented cases of masseter spasm with etomidate. my luck.

anyone else?

great job. i wouldnt fret over this. there was probably a bronchospastic component in addition to the rare etomidate-induced masseter spasm (more likely generalized myoclonus). i would have considered a little sux before pulling the tube, probably, but that carries risks too.
 
I hate etomidate without paralytic. Pt.'s never go apnic and sometimes it is difficult to get a good mouth opening. Nothing more annoying than getting a view on a difficult pt. and then they breath, cords close, and I lose my view. I now often just go straight to propofol. If they are hypotensive just give a very small dose or go with versed instead.

Why did you take the tube out after she was intubated? If you knew you were in (saw with glidescope) and thought she was biting down, just give some paralytic and wait a minute.
 
I hate etomidate without paralytic. Pt.'s never go apnic and sometimes it is difficult to get a good mouth opening. Nothing more annoying than getting a view on a difficult pt. and then they breath, cords close, and I lose my view. I now often just go straight to propofol. If they are hypotensive just give a very small dose or go with versed instead.

Why did you take the tube out after she was intubated? If you knew you were in (saw with glidescope) and thought she was biting down, just give some paralytic and wait a minute.

👍 Absolutely - if you see them clenching their teeth, there are lovely unclenching drugs available.
 
it wasn't masseter spasm.

it was lightly sedated pt with annoying object in mouth and trachea. it was a normal biting reaction.

give roc + more sedation.

also vote to not pull tube out - bad rookie idea. however, if pt is really bucking and sucking whilst you are waiting for drugs to work, take down cuff just enough to leak so you don't compound problems with negative pressure pulmonary edema.

above scenario could have been avoided by simply: optimizing position ie at least 30deg hob while preo2ing c cpap, then delivering small induction agent c rapidly acting paralytic (sux c ok k, roc o/w), glidescope c inline stabilization, +/- esmolol for cad issue.

your case illustrates why i don't believe in the "sedated" look and intubation. in my book patients are asleep and still, or awake. once you char the bridge c sedation, there is a good chance a tenuous patient will develop brain damage prior to waking up enough to regenerate sufficient ventilation, so why even go there? awake, or sleep/y/paralyzed.

choose a path, and proceed.
 
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