i had a patient who was predicted to be difficult for bag mask ventilation and laryngoscopic view (short neck, short TMD, large tongue, edentulous and no artificial teeth) ..the patient 65 years old, estimated weight 60 Kg, diagnosed as hemorrhagic stroke causing intracerebral edema (detected by CTscan)..this patient had a GCS of 6-7(still has gag reflex), so we wanted to intubate the patient..the vital signs was still quiet stable.
we intubated the patient with propofol 6o mg only (i didn't want to use the our only available muscle relaxant succynilcholin because i was afraid with its effect on ICP and the difficult airway).. after reaching the time to peak effect of propofol, i tried to intubate the patient, but the mouth was still very stiff in this patient and so, it was so hard for me to intubate this patient. i think i might have made mistakes in this patient and i need to evaluate myself so,i need to ask some questions to all of you...
1.actually, is it possible to proceed intubation without any drugs? when? and on what GCS will it be?
2. how can i manage the stiffness? should i increase the dose of propofol?thx u
Just my 2 cents from an EM perspective (hope you guys don't mind me chiming in)...already agree with most that has been said. I'm assuming this was a pt in your ED? You mentioned that you were a GP, so were you moonlighting in a rural ED somewhere?
My take is this...The dude has a hemorrhagic stroke with a decreasing GCS. He probably doesn't need to sit around down there in the ED for a prolonged period of time. Time is brain. If you spend too long getting his airway, great... but if he turns into a vegetable for lack of NSGY intervention, then your airway didn't really improve the outcome. I realize that failed airway def doesn't improve outcome either but the overall whole picture needs to be viewed here. He needs to get tubed, and fast, hyperventilated, bed 30 degrees, the whole lower ICP stuff, stabilized and either transported somewhere with NSGY available, or put straight in the ICU asap if you have NSGY in house. If you were in a rural ED, it sounds like the guy needs to get transported immediately. I understand your reticence in intubating, but you're in a bind in a situation like this... If you don't feel confident in your intubation skills, you need an anesthesiologist or another proficient airway person in house at all times while you're working the ED. Either that, or gain some additional airway training would be the easiest way to increase your confidence. Awake intubation takes longer, needs pt cooperation to some extent, risks aspiration, prolongs your laryngoscopy and is going to end up overly stimulating the physiologic reflexive surge in catecholamine release which will drive the ICP even higher. I'm a proponent of awake intubations, in the right condition. I don't personally consider this a right condition.
If you're going to intubate him, as has already been said, maximize your ability to do it successfully. The whole point to awake is so the pt will be able to breathe on his own. He's got a hemorrhagic stroke with a declining GCS. Chances are, his GCS is not going to improve and with a GCS of 6-7 the reality is that he's going to quickly reach a point where he can't protect his airway at all.
Physiologic reflex induced catech surge from prolonged laryngoscopy = increased ICP. SCH induced fasciculations = increased ICP (how much? I don't know...) With a 60kg guy, and no contraindications to Succ, I'd prob use your fastest acting and shortest duration RSI agents. Succ and etomidate with some fentanyl and lidocaine to mitigate some of the ICP issues. You want him paralyzed to increase your chances of success and you for sure don't want this guy vomiting halfway through your awake or merely sedated attempt and risk an aspiration.
Back up devices... What do you have? Glidescope, LMA, bougie, hell....combitube or king air device if you got desperate (I'm assuming you don't have fiberoptics or would feel comfortable doing a cric(not that it would be indicated in this case anyway)..). Anything to secure his airway and get him somewhere to get the bleeding inside of his head fixed. If he herniates from increased ICP 2/2 your intubation, he would have herniated soon anyway before he could have even made it anywhere for an intervention. Also, with a 60kg guy, I find it difficult to believe that an OPA/NPA with bagging until the short acting agents wear off would not be sufficient to ventilate him.
In short, I say maximize your chances of success with this guy and get him to a neurosurgeon once the airway is established and he's stabilized for transport.
Also, in retrospect... You intubated him with 60mg of propofol... In that case, you def could have done it easier with full muscle relaxation and not running the risk of aspiration. His reflex induced ICP from the intubation with prop alone I would say was def greater than if you had paralyzed him and given him an opioid analgesic with or without lidocaine during RSI.
Just my 2 cents.
Well now that you put it that way, I guess ketap should have done nothing.
