Knowing when to intubate versus when to not intubate

[deleted1139416]

This is a very frustrating question on UWORLD. I understand that in some circumstances, such as anaphylaxis or croup, you would use epinephrine and racemic epi, respectively, over intubation. But for something like opioid intoxication, UWORLD sometimes says that intubation is the right first choice and sometimes naloxone is the right first choice. So should I assume that if there is a fast way to reverse respiratory depression, I wouldn't choose intubation? For example, if someone has a RR of 4 due to benzo overdose, would flumazenil be the right choice over intubation if they were both answer choices?

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[Dr. Basketball]

Flumazenil use in the ER in a benzo overdose is controversial because it can trigger a seizure if the patient is a long time user of either benzos or alcohol.(We did a simulation and our pt. had OD'd on benzos and we gave flumazenil, that is the only reason I know that.)

Here are the indications for intubations according to Uptodate:

In emergency medicine, the most common indications for tracheal intubation are acute respiratory failure, inadequate oxygenation or ventilation, and airway protection in a patient with depressed mental status.

When I was doing questions, I remember a lot of times when the right answer was to intubate, it was because the GCS was low.

Maybe someone else can explain this better than I can. Hope this helps!

 

[TooMuchResearch]

This is a very frustrating question on UWORLD. I understand that in some circumstances, such as anaphylaxis or croup, you would use epinephrine and racemic epi, respectively, over intubation. But for something like opioid intoxication, UWORLD sometimes says that intubation is the right first choice and sometimes naloxone is the right first choice. So should I assume that if there is a fast way to reverse respiratory depression, I wouldn't choose intubation? For example, if someone has a RR of 4 due to benzo overdose, would flumazenil be the right choice over intubation if they were both answer choices?

Don't intubate opioid overdoses before massive narcan doses.

Do you have any specific examples that I can try to provide a more nuanced take?

 

[esob]

GCS 8 = intubate. The exception on NBME is usually if the person is found down with no info, AND Naloxone is an option. The only other weird NBME scenarios that I remember are burns. If you suspect someone is undoubtedly going to lose their airway from impending edema, intubate.

 

[Redpancreas]

This is a very frustrating question on UWORLD. I understand that in some circumstances, such as anaphylaxis or croup, you would use epinephrine and racemic epi, respectively, over intubation. But for something like opioid intoxication, UWORLD sometimes says that intubation is the right first choice and sometimes naloxone is the right first choice. So should I assume that if there is a fast way to reverse respiratory depression, I wouldn't choose intubation? For example, if someone has a RR of 4 due to benzo overdose, would flumazenil be the right choice over intubation if they were both answer choices?

Warning: Step 2 rant incoming:

Some general advice from someone who struggled with Step 2 CK scoring below the average but did very well on Step 1 more than a SD above the average…despite putting effort into both.

With Step 1, it’s about applying the basic science you spent a while learning logically to scenarios through deductive reasoning. To me, this is what science is.

I think with Step 2 CK it’s about using more common sense and looking at the big picture but then memorizing a few exceptions to common sense. I hated the exam and think it rewarded people for not thinking as deeply.

As this applies to this question, when you have a near comatose patient, you intubate them…unless you have a patient with opiate toxicity because Naltrexone works in seconds if you’ve seen it work in a clinical setting and hence you limit the risk of a procedure. I feel to do well on CK, you had to either just accept things you read without understanding the mechanism or really what’s going on. Once you’re a resident and see narcan work you’ll never forget it and when I had the residency experience that’s when I did well on In-Training/Step 3.

In terms of flumazenil, again, this is why I hate Step 2 CK…logically it should be the same case as it’s a drug to reverse the patients status but the thing is flumezanil is “not really a thing” in medicine and I’m not sure how you’re supposed to just know that without doing residency. It’d also frustrating because if it’s not really a thing, why did we learn about it in pharmacology? I’m not sure exactly why not but I don’t think the effects of flumezanil are as immediate and there’s some theoretical risk for seizures from the acute anti-GABA (excitatory) effect from acute reversal of the gaba medication. .

 

[Arcan57]

As this applies to this question, when you have a near comatose patient, you intubate them…unless you have a patient with opiate toxicity because Naltrexone works in seconds if you’ve seen it work in a clinical setting and hence you limit the risk of a procedure. I feel to do well on CK, you had to either just accept things you read without understanding the mechanism or really what’s going on. Once you’re a resident and see narcan work you’ll never forget it and when I had the residency experience that’s when I did well on In-Training/Step 3.

In terms of flumazenil, again, this is why I hate Step 2 CK…logically it should be the same case as it’s a drug to reverse the patients status but the thing is flumezanil is “not really a thing” in medicine and I’m not sure how you’re supposed to just know that without doing residency. It’d also frustrating because if it’s not really a thing, why did we learn about it in pharmacology? I’m not sure exactly why not but I don’t think the effects of flumezanil are as immediate and there’s some theoretical risk for seizures from the acute anti-GABA (excitatory) effect from acute reversal of the gaba medication. .

Flumazenil is something that you should have learned about in pharmacology during pre-clinical work, including contraindications. The piece that's missing in your analysis of overdose reversal is the difference between opioid withdrawal and benzo withdrawal. Naltrexone and flumazenil both induce acute withdrawal in patients with chronic use of opioids and benzos, respectively. Opioid withdrawal is physically and psychologically unpleasant but non-fatal. Benzo withdrawal is similar to alcohol withdrawal in that it can lead to intractable seizures and death.

In someone that is opioid or benzo naive, the risk/benefit ratio heavily favors adminstration of either drug in the setting of accidental/iatrogenic overdose. So the 4 yr old that got too much versed for procedural sedation would get flumazenil rather than intubated. The 45 yo with hx of anxiety on scheduled xanax would get intubated and wait to metabolize to freedom.

In regards to another commentator, if the RR is 4 it's not because of benzos (at least in the setting of a test). Benzos potentiate a lot of substances that impair respiration but by themselves cause impairment of consciousness with relatively little effect on vital signs.

 

[Redpancreas]

Flumazenil is something that you should have learned about in pharmacology during pre-clinical work, including contraindications. The piece that's missing in your analysis of overdose reversal is the difference between opioid withdrawal and benzo withdrawal. Naltrexone and flumazenil both induce acute withdrawal in patients with chronic use of opioids and benzos, respectively. Opioid withdrawal is physically and psychologically unpleasant but non-fatal. Benzo withdrawal is similar to alcohol withdrawal in that it can lead to intractable seizures and death.

In someone that is opioid or benzo naive, the risk/benefit ratio heavily favors adminstration of either drug in the setting of accidental/iatrogenic overdose. So the 4 yr old that got too much versed for procedural sedation would get flumazenil rather than intubated. The 45 yo with hx of anxiety on scheduled xanax would get intubated and wait to metabolize to freedom.

In regards to another commentator, if the RR is 4 it's not because of benzos (at least in the setting of a test). Benzos potentiate a lot of substances that impair respiration but by themselves cause impairment of consciousness with relatively little effect on vital signs.

Thanks. That’s a pretty logical explanation. I would say I'm not sure how I'd have access to perspective this as a student. but maybe I'm making excuses. .