RSI Roc before etomidate?

[thegenius]

For those who use roc and etomidate for RSI, we’re you taught to push roc before etomidate, to help reduce apneic oxygenation time? This is opposed to sux, where you push etomidate first then sux.

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[bravotwozero]

Never heard of that before and frankly, that sounds kinda scary and cruel for the patient….

 

[southerndoc]

If the patient is a crashing patient, yes. It takes about 40-60 seconds for roc to fully work. This is <1% of patients. I may have asked the nurse to do it two or three times out of countless intubations (>500).

 

[GassYous]

I mix drugs in one syringe and push together. You can tube as fast as you can for sux even without double dose. Works for video scopes, may need more time if you're going to be using dl.

I've pushed roc before anesthetic and the patient knew. They said they felt like they were getting short of breath. I gave versed so fast. Please don't give paralytic first.

If they are crashing they don't even need paralytic. You can tube them with just a scope and a tube.

 

[nimbus]

I mix drugs in one syringe and push together. You can tube as fast as you can for sux even without double dose. Works for video scopes, may need more time if you're going to be using dl.

I've pushed roc before anesthetic and the patient knew. They said they felt like they were getting short of breath. I gave versed so fast. Please don't give paralytic first.

If they are crashing they don't even need paralytic. You can tube them with just a scope and a tube.

Same. I’ve been mixing propofol, roc, and lidocaine in the same syringe for about 15 years. As soon as the patient is apneic, I intubate. Works fast, works great, and never had recall.

 

[clibby]

Last thing I want is a patient to be alert while paralyzed. I go etomidate then roc/sux, though I don’t wait between the pushes. Mixing in the syringe takes time and adds more risk of error. Haven’t had an issue yet. One place I work has suc/Vec and if I am using vec (which I hate using for RSI) I push that first as it takes so long to work. I also make sure I order analgesia in addition to sedation as having an ett hurts. If they can tolerate it, I almost always make sure I have fentanyl with my propofol/versed drip. If there is any delay in sedation, I give the rest of the etomidate so they don’t suffer.

 

[Tenk]

I push a decent amount of propofol instead of etomidate so usually they become apneic much faster than with etomidate. The paralytic is mostly to inhibit gag reflex at that point. Never had an issue but also the time between roc and propofol is probably just like 5-10 seconds or so.

 

[GassYous]

Last thing I want is a patient to be alert while paralyzed. I go etomidate then roc/sux, though I don’t wait between the pushes. Mixing in the syringe takes time and adds more risk of error. Haven’t had an issue yet. One place I work has suc/Vec and if I am using vec (which I hate using for RSI) I push that first as it takes so long to work. I also make sure I order analgesia in addition to sedation as having an ett hurts. If they can tolerate it, I almost always make sure I have fentanyl with my propofol/versed drip. If there is any delay in sedation, I give the rest of the etomidate so they don’t suffer.

How does it take more time? You open one syringe and pull meds into it. It's the fastest. It takes me like a minute to set up for a case while a few of my partners are messing around with labels and 10 syringes for ten minutes. Makes no sense and so wasteful for no reason. Don't even get me started with the whole push meds then flush between each one nonsense that nurses do.

 

[lucid_leprechaun]

For those who use roc and etomidate for RSI, we’re you taught to push roc before etomidate, to help reduce apneic oxygenation time? This is opposed to sux, where you push etomidate first then sux.

As long as you use a higher dose of Roc onset should be appropriate, I would never give before sedative. Same reason as having a drip at bedside for post intubation sedation, sounds like a special kind of hell to be intubated, paralyzed, and aware. I usually use 1.2-1.5 mg/kg Rocuronium for RSI and it gives a much faster onset. But yeah was not taught that.

 

[Angry Birds]

How does it take more time? You open one syringe and pull meds into it. It's the fastest. It takes me like a minute to set up for a case while a few of my partners are messing around with labels and 10 syringes for ten minutes. Makes no sense and so wasteful for no reason. Don't even get me started with the whole push meds then flush between each one nonsense that nurses do.

You've just changed my practice.
However, I am confident my nurses will balk.

 

[southerndoc]

If they are crashing they don't even need paralytic. You can tube them with just a scope and a tube.

So wait until they code to intubate without RSI. Got it.

 

[Mr. Vandemar]

The Hennepin way is always paralytic before sedative for RSI, regardless of the paralytic. I can’t really remember the rationale now, but it has long been the way there and there are some papers out there about it, probably from Brian Driver.

 

[Jabbed]

This was an interesting article that simulated RSI in 5000 patients in order to assess for the incidence of anesthetic awareness when pushing paralytics before sedatives. They used ketamine 2 mg/kg rather than etomidate, by the onset of action and peak effect are fairly similar.

Episode 186: The risk of anesthetic awareness when giving rocuronium before ketamine (rocketamine) in rapid sequence intubation - Pharmacy Joe -

I’m not sure if there is any real clinical significance in achieving optimal intubating conditions 10 seconds faster than if you had pushed sedatives first. Most peri-intubation cardiovascular collapse that I’ve seen have been fairly smooth tubes but have had other factors (hypotension, pulmonary HTN, refractory hypoxia) that seemed more contributory and are more a consequence of increased intrathoracic pressure than transient hypoxia.

 

[Jabbed]

How does it take more time? You open one syringe and pull meds into it. It's the fastest. It takes me like a minute to set up for a case while a few of my partners are messing around with labels and 10 syringes for ten minutes. Makes no sense and so wasteful for no reason. Don't even get me started with the whole push meds then flush between each one nonsense that nurses do.

I don’t even have access to the Pyxis in the ED, which means that I’m instructing my nurse or pharmacist to do something that is against their ingrained training and more likely to result in an error. I could ask them to pull it for me and draw it up myself, but I’m frequently doing other things like positioning the airway, double checking intubation equipment, establishing access, and herding the cats. I also seldom draw up meds myself as again, I don’t have access to the Pyxis, and there’s a reasonable chance that I’ll just screw up the dosing.

 

[Fox800]

If you are using rocuronium and ketamine, the ketamine will go in to effect faster than the rocuonium...appropriate dose 1.2 mg/kg for roc and usually 2 mg/kg for ketamine. Hence roc before ketamine (ketamine works first even though it is pushed second).

I ask the nurses to rapidly push the rocuronium and flush it with the ketamine. None of this slow push then saline flush in between (drives me nuts).

 

[Fox800]

The Hennepin way is always paralytic before sedative for RSI, regardless of the paralytic. I can’t really remember the rationale now, but it has long been the way there and there are some papers out there about it, probably from Brian Driver.

Rocuronium was the preferred drug, and it has a slower onset than ketamine. Also, if your IV were to blow mid-push, you want to have the paralytic in if possible (if you have a choice between only 1 drug).

 

[Apollyon]

So wait until they code to intubate without RSI. Got it.

That sounds unnecessarily argumentative and/or dismissive. There was no mention of "waiting". Patients crash on their own schedule.

 

[Fox800]

I mix drugs in one syringe and push together. You can tube as fast as you can for sux even without double dose. Works for video scopes, may need more time if you're going to be using dl.

I've pushed roc before anesthetic and the patient knew. They said they felt like they were getting short of breath. I gave versed so fast. Please don't give paralytic first.

If they are crashing they don't even need paralytic. You can tube them with just a scope and a tube.

Aren't paralytics proven to improve intubating conditions? If they are moribund/periarrest you could do paralytic only.

It's rare I have someone so profoundly depressed they can be intubated easily without paralysis (last one had herniated PTA).

 

[Radetzky]

As long as meds are given straight one after the other and a big enough dose of roc it really doesn’t matter.

 

[Rekt]

Never. I don't see any benefit at all.

Many times nowadays I'm using straight ketamine until the ETT is sliding through the cords then I push roc at the same time. Typically just to optimize post ETT vent settings, prevent desync, getting drips set up, OG, Foley, etc.

If they're periarrest then it doesn't matter. I've done tons of tubes in awake pts with nothing.

 

[WilcoWorld]

Appreciate the above discussion.

I'll add that if we're giving both in rapid succession the order doesn't matter so much. The more clinically impactful question may be: How do we achieve adequate & safe post-intubation sedation in the ED? It surely isn't Ativan.

 

[bravotwozero]

Appreciate the above discussion.

I'll add that if we're giving both in rapid succession the order doesn't matter so much. The more clinically impactful question may be: How do we achieve adequate & safe post-intubation sedation in the ED?
Hint: It ain't Ativan.

Usually propofol gets the job done. If not, ill give ketamine periodically.

 

[IMGASMD]

So wait until they code to intubate without RSI. Got it.

This goes hand in hand with “etomidate, sux, tube” on a patient who has been coded for 45 mins in the field.

You really don’t need paralytics to intubate. Sure the drugs makes the condition better, but do you “need” it? Nah.

 

[Siggy]

This goes hand in hand with “etomidate, sux, tube” on a patient who has been coded for 45 mins in the field.

You really don’t need paralytics to intubate. Sure the drugs makes the condition better, but do you “need” it? Nah.

Yep... rarely do I paralyze... the the vast majority of those over the past 2 years have been for the team's safety while intubating COVID patients (can't aersolize if you're paralyzed).

I'll have it on standby, but I don't normally need it.

 

[Radetzky]

Appreciate the above discussion.

I'll add that if we're giving both in rapid succession the order doesn't matter so much. The more clinically impactful question may be: How do we achieve adequate & safe post-intubation sedation in the ED? It surely isn't Ativan.

Propofol?

 

[Mr. Vandemar]

Appreciate the above discussion.

I'll add that if we're giving both in rapid succession the order doesn't matter so much. The more clinically impactful question may be: How do we achieve adequate & safe post-intubation sedation in the ED? It surely isn't Ativan.

Propofol? Ketamine? 🤨

 

[nimbus]

I don’t even have access to the Pyxis in the ED, which means that I’m instructing my nurse or pharmacist to do something that is against their ingrained training and more likely to result in an error. I could ask them to pull it for me and draw it up myself, but I’m frequently doing other things like positioning the airway, double checking intubation equipment, establishing access, and herding the cats. I also seldom draw up meds myself as again, I don’t have access to the Pyxis, and there’s a reasonable chance that I’ll just screw up the dosing.

EM and anesthesia workflows are VERY different.


In the OR, anesthesiologists have immediate access to a slew of drugs and equipment which may require time to get in the ED. So what works very well in one setting may not be ideal in another setting. Also in anesthesia, it’s against our basic nature (paranoid and untrusting😉) to push drugs we didn’t draw up ourselves or to have other people push drugs for us. That’s why I like everything in one syringe. I can hold the mask and preoxygenate with one hand while I push the one syringe with my other hand.


Also anesthesiologists are clueless at reducing wrist fractures and shoulders😉

 

[nimbus]

Appreciate the above discussion.

I'll add that if we're giving both in rapid succession the order doesn't matter so much. The more clinically impactful question may be: How do we achieve adequate & safe post-intubation sedation in the ED? It surely isn't Ativan.

Propofol infusion in-line ready to go, if hemodynamically tenuous, norepi infusion in line or running at low dose prior to induction.

 

[nimbus]

This goes hand in hand with “etomidate, sux, tube” on a patient who has been coded for 45 mins in the field.

You really don’t need paralytics to intubate. Sure the drugs makes the condition better, but do you “need” it? Nah.

What’s ED95 of etomidate on corpses?

 

[IMGASMD]

What’s ED95 of etomidate on corpses?

“I was demonstrating for the trainees, as a teaching point….”

I left.

 

[southerndoc]

This goes hand in hand with “etomidate, sux, tube” on a patient who has been coded for 45 mins in the field.

You really don’t need paralytics to intubate. Sure the drugs makes the condition better, but do you “need” it? Nah.

Pretty convincing literature out there that RSI improves first-pass success over sedation alone. I personally don't like to use brutane to intubate someone. Sure, you can do it, but it's not ideal. I would much rather improve my chances of first pass success with someone who isn't clenching down. All of my intubations (except cardiac arrest) get etomidate and rocuronium.

 

[IMGASMD]

Pretty convincing literature out there that RSI improves first-pass success over sedation alone. I personally don't like to use brutane to intubate someone. Sure, you can do it, but it's not ideal. I would much rather improve my chances of first pass success with someone who isn't clenching down. All of my intubations (except cardiac arrest) get etomidate and rocuronium.

I am sure there’s some nuance in the situations that we are picturing.

I can also tell you, the only few rescue airways that I have ever done in the ED are all because they’ve paralyzed the patient, and had a multiple go at it. Now it’s an emergency airway or surgical airway time. Please forgive me if I’m not a big fan of give paralytics to everyone nor waiting for anyone to code before placing the tube.

 

[Rekt]

I am sure there’s some nuance in the situations that we are picturing.

I can also tell you, the only few rescue airways that I have ever done in the ED are all because they’ve paralyzed the patient, and had a multiple go at it. Now it’s an emergency airway or surgical airway time. Please forgive me if I’m not a big fan of give paralytics to everyone nor waiting for anyone to code before placing the tube.

Sounds like your ED docs suck. I would never call gas for a cric.

Nowadays should almost never happen anyway. Slow sequence intubation, awake tubes, VL, bougie, intubating bronchoscopes, etc.

 

[IMGASMD]

Sounds like your ED docs suck. I would never call gas for a cric.

No argument with you there.

 

[thegenius]

Appreciate the above discussion.

I'll add that if we're giving both in rapid succession the order doesn't matter so much. The more clinically impactful question may be: How do we achieve adequate & safe post-intubation sedation in the ED? It surely isn't Ativan.

Why not Ativan. 2 mg IV knocks out a lot of people. I could also fiddle around with versed drips but then we are replacing one benzo with another benzo.

I’ve tried propofol in the past and it always succeeds in causing nasty hypotension.

 

[Jabbed]

Why not Ativan. 2 mg IV knocks out a lot of people. I could also fiddle around with versed drips but then we are replacing one benzo with another benzo.

I’ve tried propofol in the past and it always succeeds in causing nasty hypotension.

It depends on boarding honestly. We’re very short term focused in resuscitation. We snow patients rather than target light sedation. We paralyze for vent synchrony rather than stand there fiddling with the vent for 15 minutes. That’s all fine, but if you’re boarding for more than an hour you’ll be ordering multiple Ativan pushes. I seldom go higher than 0.1 mcg/kg/min on norepinephrine in order to compensate for propofol induced hypotension. In my work flow at least, it’s a tidier solution compared to rushing to the bedside every hour because the patient is bucking the vent or biting the tube.

 

[RustedFox]

Sounds like your ED docs suck. I would never call gas for a cric.

Nowadays should almost never happen anyway. Slow sequence intubation, awake tubes, VL, bougie, intubating bronchoscopes, etc.

Intubating bronchoscopy for the win.

We used to have one at old shop.
I want one at new shop.

 

[Janders]

I have done paralytic prior to sedation, basically only in first wave COVID, where the patients were arriving rapid-fire, often peri-arrest or in severe respiratory distress, and we were not allowed to use HFNC or NIV to try and pre-oxygenate them. So you’d have a moribund or delirious patient with a saturation of <70% on NC + NRB, RR=40, and maybe one RN in the room with you trying to get the single shared PAPR from the RN that just was in another room…

Anyway, in that lovely circumstance where the brief period of 10-30s of respiratory depression / apnea from sedation prior to the paralytic kicking enough to get your laryngoscope in their mouth might actually kill them right then and there, and you were told to avoid BVM as much as possible… I, having flushed the PIV hard to make sure it worked, would give high-dose slug of Roc followed by high-dose slug of Ketamine 10 seconds later, and a couple flushes.

I will say the few times I did this, they went from breathing fast to perfect intubation conditions in under 5 seconds. None of that 20-30s of sorta getting sleepy and loose but not fully relaxed stuff. And both drugs last long enough I could then swing around the side of the bed, drop a CVL in, and give the extremely strained RN team enough time to find some drip or vials of versed to keep them down.

ANYWAY, the indication for this as routine practice, IMHO, is relatively narrow. And it went against the ingrained experience of my RN staff, so it was something we’d rehearse prior to going into the room as our plan. And did it REALLY help patient-centered outcomes? Probably not. But it felt like a controllable move we could do to optimize an extremely suboptimal situation.

I’ve regressed to good ‘ol Etomidate and Sux now

 

[WilcoWorld]

Usually propofol gets the job done. If not, ill give ketamine periodically.

Propofol?

Propofol? Ketamine? 🤨

Propofol infusion in-line ready to go, if hemodynamically tenuous, norepi infusion in line or running at low dose prior to induction.

Why not Ativan. 2 mg IV knocks out a lot of people. I could also fiddle around with versed drips but then we are replacing one benzo with another benzo.

I’ve tried propofol in the past and it always succeeds in causing nasty hypotension.

I didn't mean to suggest I have the ONE right answer. I think there are a lot of ways to do it, many mentioned above, but I think an essential component is often overlooked: providing adequate analgesia rather than simply using sedatives alone. If I start by providing analgesia (usually fentanyl boluses in the initial periintubation period) I typically can use lower sedative doses.

As for why not ativan? Because the use of benzodiazepines in the ED is strongly correlated with delirium on the inpatient side (even in kids) as well as longer time to extubation when compared with other sedatives (propofol/dexmedetomidine/etc). If you decrease your benzo use in the ED, your intensivists will thank you.

 

[Rekt]

I have done paralytic prior to sedation, basically only in first wave COVID, where the patients were arriving rapid-fire, often peri-arrest or in severe respiratory distress, and we were not allowed to use HFNC or NIV to try and pre-oxygenate them. So you’d have a moribund or delirious patient with a saturation of <70% on NC + NRB, RR=40, and maybe one RN in the room with you trying to get the single shared PAPR from the RN that just was in another room…

Anyway, in that lovely circumstance where the brief period of 10-30s of respiratory depression / apnea from sedation prior to the paralytic kicking enough to get your laryngoscope in their mouth might actually kill them right then and there, and you were told to avoid BVM as much as possible… I, having flushed the PIV hard to make sure it worked, would give high-dose slug of Roc followed by high-dose slug of Ketamine 10 seconds later, and a couple flushes.

I will say the few times I did this, they went from breathing fast to perfect intubation conditions in under 5 seconds. None of that 20-30s of sorta getting sleepy and loose but not fully relaxed stuff. And both drugs last long enough I could then swing around the side of the bed, drop a CVL in, and give the extremely strained RN team enough time to find some drip or vials of versed to keep them down.

ANYWAY, the indication for this as routine practice, IMHO, is relatively narrow. And it went against the ingrained experience of my RN staff, so it was something we’d rehearse prior to going into the room as our plan. And did it REALLY help patient-centered outcomes? Probably not. But it felt like a controllable move we could do to optimize an extremely suboptimal situation.

I’ve regressed to good ‘ol Etomidate and Sux now

Can this be physiologically explained to me?

I don't see how there's a difference from an apnea standpoint. You're either paralyzing the diaphragm causing apnea or they're apneic from sedation. Unless people are taking a really long time to intubate and riding the sedation it doesn't really make sense.

Unless it's a high tier difficult airway, then RSI should be 60 seconds max real. 30-45seconds for roc. The rest for the tube.

Also, I've used roc hundreds of times and for sure it never works that quick? I always see other residents try to tube too fast after roc. I specifically use high dose etomidate and sux for covid pts to drop them immediately and tube as fast as possible because they always get massive atelectasis and take forever to recover on the vent.

 

[Jabbed]

Can this be physiologically explained to me?

I don't see how there's a difference from an apnea standpoint. You're either paralyzing the diaphragm causing apnea or they're apneic from sedation. Unless people are taking a really long time to intubate and riding the sedation it doesn't really make sense.

Unless it's a high tier difficult airway, then RSI should be 60 seconds max real. 30-45seconds for roc. The rest for the tube.

Also, I've used roc hundreds of times and for sure it never works that quick? I always see other residents try to tube too fast after roc. I specifically use high dose etomidate and sux for covid pts to drop them immediately and tube as fast as possible because they always get massive atelectasis and take forever to recover on the vent.

Your peak intubation conditions will be dependent on the peak effect of your paralytic, not your sedative. The sooner you push your paralytic (and the higher the dose), the sooner you will achieve ideal RSI conditions. The nightmare scenario that we’re envisioning is the hypoxic patient that has become apneic from sedation but is still clench jawed and unable to be intubated and is difficult to BVM or vomits during BVM. The overall incidence of this is low and it’s unclear much those few seconds of apnea where you can’t successfully intubate really make a difference clinically, but you’re definitely tight sphinctered when it happens to you.

 

[Janders]

Agree with my above colleague, and also posit we’re splitting theoretical hairs for fun at this point.

In my experience with standard dosed etomidate followed some 15-30 seconds later by sux, patients often have a 30-40s period of drifting to sleep where they have shallow respirations but not complete relaxation. You can usually intubate through it if needed. And 99% of the time you can just use a basic airway maneuver, bag them a bit, or… just wait because you pre-oxygenated.

With the high dose Roc (and I’m sure with sux as well… I was using roc d/t high incidence of AKI and HyperK in these incoming patients, and for duration of action after intubation letting me get them settled in auster environs) followed some time later with ketamine or etomidate, I got more of a sudden light switch effect where they went from breathing to loose in 5 seconds.

Now is some 20-30s of additional peri-apnea really going to matter? Probably not.

And now that we’re allowed to use NIV to pre-oxygenation, or BVM when needed, and have been vaccinated ourselves, I haven’t been doing this any more.

 

[Jabbed]

Slight hijack, but I think that a more clinically relevant question is “what dose of Rocuronium are you using?” Roc comes in vials of 50 mg, which means most times you’re probably closer to 0.6 mg/kg dosing. There’s great evidence that higher dose roc achieves NM blockade faster than lower dose. Most times, it doesn’t matter as you can wait 60 seconds as long as someone’s oxygenated and baggable. I’ll increase the dose for fluffy patients and low-flow shock patients up to 1.2 mg/kg, but there are plenty of people smarter than I (Josh Farkas) who advocate going for doses as high as 1.4-2.0 mg/kg in low perfusion states.

Bonus is that your post-intubation CVL/chest tube/nursing procedures are much, much easier. Just remember to start some sedation concurrently.

 

[Janders]

Yes. In those cases I was using more than one vial, and the duration of Roc/Ket was very useful to (1) find a vent setting that worked and (2) get CVL and all the pumps and drips set up. I don’t miss first wave.

 

[gamerEMdoc]

Ive heard that if using Vec a long time ago, but not roc. Roc has a pretty quick onset of action, I don't know why you'd need to do this.

 

[southerndoc]

Slight hijack, but I think that a more clinically relevant question is “what dose of Rocuronium are you using?” Roc comes in vials of 50 mg, which means most times you’re probably closer to 0.6 mg/kg dosing. There’s great evidence that higher dose roc achieves NM blockade faster than lower dose. Most times, it doesn’t matter as you can wait 60 seconds as long as someone’s oxygenated and baggable. I’ll increase the dose for fluffy patients and low-flow shock patients up to 1.2 mg/kg, but there are plenty of people smarter than I (Josh Farkas) who advocate going for doses as high as 1.4-2.0 mg/kg in low perfusion states.

Bonus is that your post-intubation CVL/chest tube/nursing procedures are much, much easier. Just remember to start some sedation concurrently.

Our RSI kits include 100 mg of rocuronium and 200 mg of SCH. I usually give 20-25 mg etomidate + 100 mg rocuronium on nearly every patient. The very little patients get 50 mg. Have to remember to start your sedation very early after intubation. The etomidate will wear off and the patient will be paralyzed, intubated, and aware of everything going on.

 

[Janders]

Ive heard that if using Vec a long time ago, but not roc. Roc has a pretty quick onset of action, I don't know why you'd need to do this.

Someone did a retrospective study and it gets you like 5-10s of improvement in total apnea time during RSI iirc. I’ll look for it later. Now, Does it matter? Nah. But neither does the classic Sux/Rod debate

I didn’t invent it, here is a better explanation of the theoretical framework—

PulmCrit- Rocketamine vs. keturonium for rapid sequence intubation

Background: Devil in the details Airway management is a detail-oriented sport. Minor nuances of patient positioning can be essential. Or gentle

emcrit.org

 

[Apollyon]

You want to know something? It leaked that the CIA used NMBs in Iraq "therapeutically". They would give captives the paralytic, and leave them conscious. What is the most terror inducing? The sense of dyspnea. After 3 or 4 minutes of sheer conscious hell, they would give a dose of neostigmine. That might give you an idea of as to what @clibby said above - paralyzed and awake.

I have never held a security clearance, and I was not there. This was leaked on the internet over 10 years ago.

 

[thegenius]

Interesting how varied the responses are for a fairly algorithmic aspect of our profession. I would think there would be little variability among ED docs for RSI.

If one does a search for "rocuronium before etomidate" or "scott weingart rocuronium before etomidate" or variations of that query, one will find several articles and discussions about the benefits. It appears the benefit is most pronounced for those with severe hypoxic respiratory failure.

Here is the reason why I originated this thread:

I responded to a code blue on the floor. Pt had a pulse, breathing, and was markedly obtunded. She had a draining chest tube out of the right hemithorax for a malignant pleural effusion. HR 120, BP 110/75, RR ~24, SpO2 100% via 100% NRB. She would open her eyes to noxious stimuli and not show me "two fingers". I had a very poor and disappointing interaction with an ICU nurse who floats around and responds to floor code blues. First I mentioned "why is this a code blue, pt isn't undergoing CPR" and she quips (paraphrasing) "code blues are not only for cardiac arrest but also for respiratory arrest for patients who need to be intubated, according to ACLS guidelines. Why is this something that I constantly have to teach or tell people about." Obviously this rubbed me the wrong way, whether she is right or wrong, as that is not the way to speak to someone at all regardless of position or rank, let alone someone who outranks her. Anyway...I grumbled a little bit and stayed. Pt did "need" to be intubated whether it was that minute or 5-20 minutes from now. For instance, if she were an undifferentiated patient who rolled into the ER like this, I would probably have done some investigative work for the next 10-15 minutes or so while being in the room to determine why she was so obtunded. You know general stuff like physical exam (can she protect her airway, stick a qtip in the back of her nose doses she wince), FSG, EKG, CXR, getting history, do I need to activate stroke, etc. So I stayed. Mind you intubating patients in floor rooms is the worst place to do it, the beds suck, there is no room to do anything, there are 10-15 people in the room, it's chaos despite all our training that we should be calm, etc.

So pt looked to be <= 60 kg, so I had nurses draw up etomidate 10 mg IV, rocuronium 100 mg IV. We set up to tube and I tell the same nurse please push roc then etomidate, one immediately after another. Now...picture this. There are at least10 people in the room, and another 5-8 leering eyes just outside the room. There is low level pitter-patter but I'm the only one talking at a normal voice. The nurse then said, in a voice louder than mine..."WHAT, you want me to push a paralytic before a sedative? I HAVE NEVER SEEN THIS BEFORE. THIS NEVER OCCURS UP IN THE ICU AND IN THE ER WHEN I'M IN THE ER. This is a terrible thing to do. I OBJECT TO DOING THIS!" I did briefly explain that due to the pharmacokinetics of the drugs, there is less apneic time, and in this case it probably doesn't even matter, but she wasn't listening. I looked around the room and there were other nurses and the hospitalist who all had eyes like 👀 and while looking at me.

I almost asked the nurse to leave the room right at that time I was so mad at her.

We proceeded with an uneventful tube and I left the room never acknowledging that nurse again. I asked one of the RT's afterwards what her name was, and he said "oh her? yea we all have problems with her." I go back to the ER fuming inside, wondering if I should write her up. I have never written anybody up. I talked to one of my fellow ER docs and she also has had problems with that RT.

About 2-3 hours later the nurse came to the ER to apologize to me. I asked her to talk to me in the supply room where nobody else was around. I don't remember her exact words, but she did give some bull**** apology like "I'm sorry BUT...." and really didn't issue a general heart felt apology. She was focused mostly on the notion I said it shouldn't be a code blue to begin with, and I responded by saying ultimately I stayed, the patient was tubed, and it was a good outcome. I left the room as she was trying to talk to me more. I was so pissed at her. With respect to timing of the paralytics and sedatives, I told her she can go talk to the attendings at Cornell where I learned this in residency.

I've decided not to write her up, but if I ever see her again in a room with a patient I'm taking care of I will ask her to leave.

 

[Radetzky]

Agree with my above colleague, and also posit we’re splitting theoretical hairs for fun at this point.

In my experience with standard dosed etomidate followed some 15-30 seconds later by sux, patients often have a 30-40s period of drifting to sleep where they have shallow respirations but not complete relaxation. You can usually intubate through it if needed. And 99% of the time you can just use a basic airway maneuver, bag them a bit, or… just wait because you pre-oxygenated.

With the high dose Roc (and I’m sure with sux as well… I was using roc d/t high incidence of AKI and HyperK in these incoming patients, and for duration of action after intubation letting me get them settled in auster environs) followed some time later with ketamine or etomidate, I got more of a sudden light switch effect where they went from breathing to loose in 5 seconds.

Now is some 20-30s of additional peri-apnea really going to matter? Probably not.

And now that we’re allowed to use NIV to pre-oxygenation, or BVM when needed, and have been vaccinated ourselves, I haven’t been doing this any more.

Why are you waiting 15-30 seconds to give the sux?