RSI Roc before etomidate?

[IMGASMD]

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
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.

You should write her up. If it was an actual “code” you lost time by wasting your explaining and repeat your orders. I would frame it as due to her insubordination, some time were lost in an emergency situation.

You were giving a direct verbal order. Any objections should have been discussed later, after you’ve confirmed again that’s what you wanted to be done.


But I also understand that you don’t want to make waves…. I’ve been bullied too when I started a new job.

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[GassYous]

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.

That behavior is completely unacceptable from start to finish. The way she said things, the way she handled herself, the direct insubordination to a direct verbal order from a physician. She needs to be fired. You don't need to explain anything to anyone. They need to do what you ordered. Write her up.

 

[Brigade4Radiant]

just right the nurse up that’s so crappy hopefully something gets done but I doubt anything will

 

[nimbus]

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.

Probably not as scary if you are aware of what’s going on and are being ventilated. I imagine it would be terrifying if you were not being ventilated even if you knew what was happening. The point of this video is to demonstrate that the BIS monitor does not work as advertised in densely paralyzed patients. This is a volunteer who is doing arithmetic while awake and paralyzed.

 

[Apollyon]

Probably not as scary if you are aware of what’s going on and are being ventilated. I imagine it would be terrifying if you were not being ventilated even if you knew what was happening.

These were ISIS prisoners, not ventilated. That was the whole torture angle. Remember "extreme interrogation", or whatever they called it? That was one of the things they did. It's another tool in the toolbox, like waterboarding.

 

[TheComebacKid]

I really don't understand a lot of the comments on here. Especially the ones pertaining to exclusive drug assisted airway without paralytic. Outside of COCV situations, cardiac arrest, completely comatose patients with clearly no reflexes, I can't envision a situation where you would attempt to intubate without paralytic. I would rather take an extra 45 seconds of apnea time with paralytic, than struggle and muck around with only etomidate/ketamine. Having "paralytic as a backup" makes no sense. There's unbelievable amounts of data that says that patients do worse with multiple intubation attempts, why not just get it right the first time and optimize things in one shot, especially if it's a more challenging airway. Plus the benefits of longer acting paralytic while they are getting set up on the vent, getting an OG tube, getting propofol drip ready etc foley etc cannot be overstated.

If they are so hypoxic that they can't tolerate the apnea time, then you should probably consider DSI or some other way to better preoxygenate them. That includes BVM. I know the goal is always to not bag them if you can avoid it to avoid gastric insufflation etc, but I have found perintubation hypoxia to be a much more common and a bigger killer than vomiting from BVM, but that's just my anecdotal experience.

I know lots of people prefer roc, but barring any contraindications, the rapid onset of succinylcholine seems to work fine in the majority of situations.

 

[Siggy]

I really don't understand a lot of the comments on here. Especially the ones pertaining to exclusive drug assisted airway without paralytic. Outside of COCV situations, cardiac arrest, completely comatose patients with clearly no reflexes, I can't envision a situation where you would attempt to intubate without paralytic. I would rather take an extra 45 seconds of apnea time with paralytic, than struggle and muck around with only etomidate/ketamine. Having "paralytic as a backup" makes no sense. There's unbelievable amounts of data that says that patients do worse with multiple intubation attempts, why not just get it right the first time and optimize things in one shot, especially if it's a more challenging airway. Plus the benefits of longer acting paralytic while they are getting set up on the vent, getting an OG tube, getting propofol drip ready etc foley etc cannot be overstated.

If they are so hypoxic that they can't tolerate the apnea time, then you should probably consider DSI or some other way to better preoxygenate them. That includes BVM. I know the goal is always to not bag them if you can avoid it to avoid gastric insufflation etc, but I have found perintubation hypoxia to be a much more common and a bigger killer than vomiting from BVM, but that's just my anecdotal experience.

I know lots of people prefer roc, but barring any contraindications, the rapid onset of succinylcholine seems to work fine in the majority of situations.

I don't know what to say. The vast vast majority of times I give someone 40 of etomidate or 30-40 of propofol they become completely flaccid and I get get a good grade 1 view without issue. I generally don't have much issues with people biting down. There certainly have been times where the airway was more difficult than expected (and not because of people clinching) where either the extra breaths the patient can take made it easier, or hearing the breaths through the ETT as I inserted it made confirmation better. The vast majority of tubes I end up getting on the first attempt.

Also if the patient is on bipap prior to intubation, I sedate +/- paralysis with bipap in place and go straight from bipap to ETT.

 

[Radetzky]

I don't know what to say. The vast vast majority of times I give someone 40 of etomidate or 30-40 of propofol they become completely flaccid and I get get a good grade 1 view without issue. I generally don't have much issues with people biting down. There certainly have been times where the airway was more difficult than expected (and not because of people clinching) where either the extra breaths the patient can take made it easier, or hearing the breaths through the ETT as I inserted it made confirmation better. The vast majority of tubes I end up getting on the first attempt.

Also if the patient is on bipap prior to intubation, I sedate +/- paralysis with bipap in place and go straight from bipap to ETT.

Are you really getting grade 1 views if you’re relying on spontaneous breath sounds to be sure of placement?

 

[Siggy]

Are you really getting grade 1 views if you’re relying on spontaneous breath sounds to be sure of placement?

Most of the time it's a grade 1 view. On the ones where it's less of a view or there's issues maneuvering the tube to the glottis, it's helpful.

Are you really getting grade 1 views if you're using tube fogging, bilateral breath sounds, absent epigastric sounds, and EtCO2 (qualitative or quantitative) to confirm placement instead of direct visualization? (yes, this is a rhetorical question).

To clarify, I'm not shoving a blade in and poking around until I hear sounds coming out of the end of the ETT.

 

[southerndoc]

I don't know what to say. The vast vast majority of times I give someone 40 of etomidate or 30-40 of propofol they become completely flaccid and I get get a good grade 1 view without issue. I generally don't have much issues with people biting down. There certainly have been times where the airway was more difficult than expected (and not because of people clinching) where either the extra breaths the patient can take made it easier, or hearing the breaths through the ETT as I inserted it made confirmation better. The vast majority of tubes I end up getting on the first attempt.

Also if the patient is on bipap prior to intubation, I sedate +/- paralysis with bipap in place and go straight from bipap to ETT.

You're able to intubate with only 30-40 mg of propofol?!?

 

[Siggy]

You're able to intubate with only 30-40 mg of propofol?!?

How much do you expect an 80 year old demented, hypoactive delirium patient to need?

It’s a bit different than the social (chemical restraint severe danger to self/others) intubation or the status epilepticus intubation or the late middle age crashing COPD/heart failure/asthma intubation.

For protocol, I normally draw up 10 mL and start with 3-4 mL. Then dose to effect.

 

[BoardingDoc]

You're able to intubate with only 30-40 mg of propofol?!?

Yeah, this seems too specific to be a typo, but this also doesn't even remotely pass the sniff test.

 

[Rockinacoustic]

I think we went through a phase of Docs trying this shortly after the Pulmcrit/EMcrit posts in 2017. In my (bystander) experience, any real-world benefits of giving Roc before your sedative if offset by the pause and discussion with an unfamiliar nurse on why we're "paralyzing before sedating". I think responding to a respiratory arrest on the floor with your non-ED nurses isn't the time to be deviating from your institution's unwritten "rules" unless you're gonna push the meds yourself.

From my understanding a lot of these Paralyze before Sedate studies used lower doses of Roc (0.6 mg/kg) whereas doses of 1.2 mg/kg have onsets similar to Succ, and durations of action similar to Vec. A poster above said they only have 50 mg vials- your pharmacy can absolutely get you 100 mg vials so you can adequately dose your patients on the higher end. I don't make the math hard and just round to the nearest 10 mg (1mL).

But, I have no skin in the game as far as intubation conditions go. I just make sure we're dosing our RSI agents correctly and starting appropriate sedation afterwards.

 

[BoardingDoc]

The vast vast majority of times I give someone 40 of etomidate or 30-40 of propofol they become completely flaccid and I get get a good grade 1 view without issue.

How much do you expect an 80 year old demented, hypoactive delirium patient to need?


For protocol, I normally draw up 10 mL and start with 3-4 mL. Then dose to effect.

Your first post was written in a way that leads one to believe that you use 30-40mL of prop routinely. You made no mention of the demented frail delirium patient until later... at which point you also explain that you don't actually give 30-40. You give 30-40 to start and then give however much more you need to get the job done, which makes sense.

 

[RustedFox]

Intubating bronchoscopy for the win.

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

Update: What's weirder is that I had no need for such a device at OldShop (Country Club Medical Center) and I really need it at NewShop (Homeless Memorial Hospital).

 

[RoyBasch]

I really don't understand a lot of the comments on here. Especially the ones pertaining to exclusive drug assisted airway without paralytic. Outside of COCV situations, cardiac arrest, completely comatose patients with clearly no reflexes, I can't envision a situation where you would attempt to intubate without paralytic.

Anticipated airway obstruction due to infection like ludwigs, tumor, tracheal stenosis, etc.

I would generally prefer to keep the patient spontaneously breathing. Also there is a chance you will experience a "ball valve" phenomenon if they become paralyzed and lose their upper airway reflexes/tone. In this situation you will now be in a CICV disaster. You're only rescue would be a surgical airway, which because of the underlying condition may be potentially difficult due to distorted anatomy.

Obviously a very rare situation, but high risk of death if not meticulously managed from a technical and pharmaceutical point of view.

There are a handful of situations where I might do paralytic only with no sedation, such as a patient who no mental status/comatose with very tenuous hemodynamics.

If the patient is in cardiac arrest then neither sedative nor paralytic is necessary unless jaw tone makes it impossible to get a view otherwise.

95% of intubations for me will be RSI with sedative/paralytic with sedative first.

 

[GassYous]

I have done many "awake looks" in threatened airways in residency. Localize up, take a look with the glide before you put them to sleep to make sure you can get a good view and then anesthetize/paralyze for the tube. It is common to get a good view without paralysis although that is kinda the point of the glide.

Sometimes we want to intubate without paralysis: anterior mediastinal mass, tamponade, cervical spine issues where you want to do a neuro exam after intubation, etc.

 

[turkeyjerky]

I'm really surprised at the varied responses in this thread. I think paralytic first is completely fine in the patient population that we would want to employ it in, plus the risk of anesthetic awareness is likely low in this population. I remember we used to talk about it during residency early last decade, but I don't think I've ever actually done it since graduation since I'd anticipate the painful conversation (and inevitable delay) that Genuis had to endure. (However, if anyone has any tips on getting nurses to skip the extended delay between sedative and paralytic then I'm all ears. Saying "push the roc immediately after the ketamine" never seems to have the desired effect. There's always a flush employed and then a look over at me followed by them saying "are you ready for the roc now?")

The sedative only intubation is just weird to me. I get that you can, but why? (not referring to the OR cases alluded to above, that's a different territory. I also doubt that you guys are talking about doing this in patient's w/ acute RV failure in order to preserve negative intrathorarcic pressure or analogous conditions)

 

[Rekt]

I'm really surprised at the varied responses in this thread. I think paralytic first is completely fine in the patient population that we would want to employ it in, plus the risk of anesthetic awareness is likely low in this population. I remember we used to talk about it during residency early last decade, but I don't think I've ever actually done it since graduation since I'd anticipate the painful conversation (and inevitable delay) that Genuis had to endure. (However, if anyone has any tips on getting nurses to skip the extended delay between sedative and paralytic then I'm all ears. Saying "push the roc immediately after the ketamine" never seems to have the desired effect. There's always a flush employed and then a look over at me followed by them saying "are you ready for the roc now?")

The sedative only intubation is just weird to me. I get that you can, but why? (not referring to the OR cases alluded to above, that's a different territory. I also doubt that you guys are talking about doing this in patient's w/ acute RV failure in order to preserve negative intrathorarcic pressure or analogous conditions)

Really pretty much what the two docs above said. It's hard to predict a true difficult airway in the ED compared to the OR imo and our patients come in with no resuscitation essentially.

Pushing a paralytic is a clean kill until you get an airway.

If you haven't done it much then it might seem wild but honestly 1.5mg/kg ketamine IV you can pretty much tube anyone keeping respiratory function intact. I've had occasional clenched jaws then just I just drop them. But I always push paralytics as I pass the cords. Don't get me wrong I do plenty of standard RSI (sedative pre paralytic for me, but my nurses have no issues pushing both immediately).

I think the pre vs post sedative is fine and ultimately won't mater 99% of the time.

Now for the craziest things I've heard in this thread is tubing with propofol for adults (I'll do i for kids and I guess an argument could be made for SE but I'd just reach for a stack of versed) and using Ativan for post ETT sedation. Now that's crazy talk.

 

[clibby]

Really pretty much what the two docs above said. It's hard to predict a true difficult airway in the ED compared to the OR imo and our patients come in with no resuscitation essentially.

Pushing a paralytic is a clean kill until you get an airway.

If you haven't done it much then it might seem wild but honestly 1.5mg/kg ketamine IV you can pretty much tube anyone keeping respiratory function intact. I've had occasional clenched jaws then just I just drop them. But I always push paralytics as I pass the cords. Don't get me wrong I do plenty of standard RSI (sedative pre paralytic for me, but my nurses have no issues pushing both immediately).

I think the pre vs post sedative is fine and ultimately won't mater 99% of the time.

Now for the craziest things I've heard in this thread is tubing with propofol for adults (I'll do i for kids and I guess an argument could be made for SE but I'd just reach for a stack of versed) and using Ativan for post ETT sedation. Now that's crazy talk.

Once you have the tube, why push the paralytic? The point of the paralytic is to optimize your intubating conditions. If they are sedated enough and you have the tube, shouldn't you just start sedation? When I have done awake intubations, I just don't use a paralytic. I have it on hand in case things go south as it makes a cric easier, but haven't needed it yet (thank goodness!) as they either are still breathing with ketamine or I get the tube.

I do agree that it is crazy pants to use propofol as in induction agent to intubate undifferentiated (usually septic) patients in the ED. The only time I use it for induction is hypertensive TBIs as I want the BP to drop. Otherwise, the hypotension is too risky and I lean on etomidate and ketamine.

 

[Rekt]

Once you have the tube, why push the paralytic? The point of the paralytic is to optimize your intubating conditions. If they are sedated enough and you have the tube, shouldn't you just start sedation? When I have done awake intubations, I just don't use a paralytic. I have it on hand in case things go south as it makes a cric easier, but haven't needed it yet (thank goodness!) as they either are still breathing with ketamine or I get the tube.

I do agree that it is crazy pants to use propofol as in induction agent to intubate undifferentiated (usually septic) patients in the ED. The only time I use it for induction is hypertensive TBIs as I want the BP to drop. Otherwise, the hypotension is too risky and I lean on etomidate and ketamine.

Because invariably the nurse comes running over about how they're bucking the vent, desynching, "we can't go to CT like this", etc. Even if sedation "was at bedside" (never is or it's titrated poorly). Sure paralytic helps intubation conditions but I'd argue it's even better for post intubation which is why I rarely use sux anymore.

 

[GassYous]

Once you have the tube, why push the paralytic? The point of the paralytic is to optimize your intubating conditions. If they are sedated enough and you have the tube, shouldn't you just start sedation? When I have done awake intubations, I just don't use a paralytic. I have it on hand in case things go south as it makes a cric easier, but haven't needed it yet (thank goodness!) as they either are still breathing with ketamine or I get the tube.

I do agree that it is crazy pants to use propofol as in induction agent to intubate undifferentiated (usually septic) patients in the ED. The only time I use it for induction is hypertensive TBIs as I want the BP to drop. Otherwise, the hypotension is too risky and I lean on etomidate and ketamine.

To keep them from bucking or chomping on the tube. Can take forever for the nurses to set up the sedation. You can always give push dose pressors (phenylephrine boluses 100-200 at a time)

 

[Radetzky]

You just need to now how to use propofol, 2-3mls is enough for a shocked pt and can achieve a stable induction.

“pushing a paralytic is a clean kill?” Wth? The DAS algorithm doesn’t even recognise an attempt as one done without paralytic. 99.9% of patients can be bagged with two hands.

 

[clibby]

Because invariably the nurse comes running over about how they're bucking the vent, desynching, "we can't go to CT like this", etc. Even if sedation "was at bedside" (never is or it's titrated poorly). Sure paralytic helps intubation conditions but I'd argue it's even better for post intubation which is why I rarely use sux anymore.

Fair point. I am fairly aggressive about making sure they are sedated when I give a paralytic. When we have time I make them set it up while we prepare to intubation and we have propofol in our Pyxis which helps. I hate it when I inherit a patient at signout who is paralyzed, but tacky and tearing which resolves when I bolus the leftover etomidate or go up on sedation.

I rarely use sux too as any repeat neuro exam isn't getting done until the patient gets back from CT and the neurosurgeon gets down to the ED at which point the roc has usually worn off or the decision to go to the OR was already made from the history and imaging; worst case you can reverse with sugammadex.

To keep them from bucking or chomping on the tube. Can take forever for the nurses to set up the sedation. You can always give push dose pressors (phenylephrine boluses 100-200 at a time)

There is a 0% chance that I can get push dose phenylephrine in the vast majority of emergency departments and only one place I work at has push dose epi when the ED pharmacist is there. That's why the ED is different than the OR. I could potentially get a phenylephrine drip from Pharmacy, but that will take 20 to 40 minutes. If I were to mix up my own norepinephrine or epi push dose from the meds in the Pyxis, I would have to do that manually. Or, I could just use etomidate or ketamine to mitigate the risk incurred with a bolus of propofol. Starting a propofol drip for sedation alongside norepinephrine is a lot more gradual.

 

[thegenius]

You just need to now how to use propofol, 2-3mls is enough for a shocked pt and can achieve a stable induction.

“pushing a paralytic is a clean kill?” Wth? The DAS algorithm doesn’t even recognise an attempt as one done without paralytic. 99.9% of patients can be bagged with two hands.

That's what I'm talking about. The variability on this topic is surprising, as well as some of the black-and-white opinions uttered as well.

 

[TheComebacKid]

Anticipated airway obstruction due to infection like ludwigs, tumor, tracheal stenosis, etc.

I would generally prefer to keep the patient spontaneously breathing. Also there is a chance you will experience a "ball valve" phenomenon if they become paralyzed and lose their upper airway reflexes/tone. In this situation you will now be in a CICV disaster. You're only rescue would be a surgical airway, which because of the underlying condition may be potentially difficult due to distorted anatomy.

Obviously a very rare situation, but high risk of death if not meticulously managed from a technical and pharmaceutical point of view.

There are a handful of situations where I might do paralytic only with no sedation, such as a patient who no mental status/comatose with very tenuous hemodynamics.

If the patient is in cardiac arrest then neither sedative nor paralytic is necessary unless jaw tone makes it impossible to get a view otherwise.

95% of intubations for me will be RSI with sedative/paralytic with sedative first.

I clearly stated in my post that outside of potential COCV situations, like the ones you are alluding to, that paralytics are indicated. The cases you are discussing probably are better suited for awake fiberoptic intubation, assuming you work in a shop that has fiberoptics.

For anatomically challenging airways I'm either going awake fiberoptic nasotracheal intubation, or, hopefully not but possibly surgical airway.

From my perspective if you have a situation like say, horrible angioedema, I don't see how ketamine only without paralytic and DL/VL helps your chances. I would argue you waste time and delay time to intubation. Also, there are plenty of people on here who have commented on how they sometimes get apnea with just induction agents alone (this is not always my experience, and even if they do go apneic often times they are still clenched which is now a double whammy bad situation).

Also, hypotensive patients in extremis who get induction meds only very frequently will arrest due to loss of sympathetic tone irrespective of whether they get paralyzed or not, so I don't see how etomidate/ketamine only approach offers much benefit in the "crashing patient" cohort.

Either you go fiberoptic/crich, or RSI with paralytic. This in between approach seems to be less than ideal and the worst of all approaches. If patient is hemodynamically tenuous or you have persistent hypoxia you resuscitate them with push dose pressors (which work very quickly) and can go with DSI to correct hypoxia.

Outside of these <1% of unique/anatomically challenging cases, RSI (induction agent + paralytic) every time. There is literally zero downside. Even if you are one of the people that likes intubating with etomidate/ketamine only, you can still push the paralytic. You can start laryngoscopy with them before they go apneic if you desire and if you are struggling the paralytic then will kick in. Again, I don't understand the downside at all.

 

[Arch Guillotti]

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

Depending on the situation could be to make sure the IV is working as evidenced by the patient falling asleep. Blown IV's happen every now and then during induction and can be hard to recognize at times. Stinks to give a high dose depot shot of roc or whatever.

 

[Arch Guillotti]

40 of etomidate

Pretty high dose.

 

[GassYous]

Depending on the situation could be to make sure the IV is working as evidenced by the patient falling asleep. Blown IV's happen every now and then during induction and can be hard to recognize at times. Stinks to give a high dose depot shot of roc or whatever.

I've had ivs blow during induction and as I'm pushing meds, it didn't seem like the im prop/roc affected their respiratory mechanics at all. I had one patient who was a really tough stick and I think I eventually put a long iv in her ij but nothing happened to her arm or her breathing.

 

[southerndoc]

Pushing a paralytic is a clean kill until you get an airway.

I agree. If you aren't skilled in intubation, then you shouldn't be doing RSI. I've had two times I couldn't get an airway after RSI. Neither patient would've been fine without an airway. It's not like you would use SCH, it wear off, patient breathes on their own, and then you say "oh we don't need an airway now." You might try a different approach, but you should've thought of that before you RSI'd the patient to begin with. In both cases I gave roc and couldn't intubate, I already had a backup plan: cric for one and fiber optic for the other. If you aren't skilled with your backup plan, you need to practice. Many times my backup plan is simply a GlideScope, but our extended airway equipment is always available. Cric, fiber optic, etc. are always a few feet away.

 

[southerndoc]

There is a 0% chance that I can get push dose phenylephrine in the vast majority of emergency departments and only one place I work at has push dose epi when the ED pharmacist is there. That's why the ED is different than the OR. I could potentially get a phenylephrine drip from Pharmacy, but that will take 20 to 40 minutes. If I were to mix up my own norepinephrine or epi push dose from the meds in the Pyxis, I would have to do that manually. Or, I could just use etomidate or ketamine to mitigate the risk incurred with a bolus of propofol. Starting a propofol drip for sedation alongside norepinephrine is a lot more gradual.

I'm lucky to have a 10 mL prefilled syringe of phenylephrine in the Omnicell of 5 of my resuscitation bays. I use it all the time for hypotensive patients I'm doing RSI on. Works great.

 

[Siggy]

Pretty high dose.

For most patients that’s going to be around 0.5 mg/kg.

I guess if people are near the bottom or under dosing etomidate then I can see why non-paralysis seems like heresy.

 

[Arch Guillotti]

For most patients that’s going to be around 0.5 mg/kg.

I guess if people are near the bottom or under dosing etomidate then I can see why non-paralysis seems like heresy.

I have pushed etomidate probably 10,000 times, at least. Never given 40.

 

[GassYous]

For most patients that’s going to be around 0.5 mg/kg.

I guess if people are near the bottom or under dosing etomidate then I can see why non-paralysis seems like heresy.

You need like 0.2

 

[BoardingDoc]

Tangentially: this has been a surprisingly enlightening look into the fact that there is a hell of a lot more variation in the way people intubate people in the ED than what I would have ever guessed.

Throwing my hat into the ring:
- Basically everyone gets 0.3mg/kg etomidate followed immediately by 1.2mg/kg roc.
- The hypotensive demented granny gets periintubation push dose neo
- The angioedema who I'm nasally fiberoptically intubating because her tongue fills her entire mouth gets lots of nebulized lido, nose dilated with increasing size nasal trumpets coated in lido gel then nasally tubed with ketamine only. I have a knife in my pocket and her neck is already prepped and marked with a sharpie.

I doubt that I'm ever going to push paralytics before sedatives as that seems potentially unfathomably cruel and even with the above examples, I really don't see how it's medically justified. If anyone has good peer reviewed data on it, I'd love to read it.

If the argument for pushing paralytics late in the RSI game is to assist with the patient bucking the vent or similar, I'd argue that the better solution is to make sure that the RN actually has post intubation sedation set up and ready to go as soon as the tube is in. Yes, that doesn't routinely happen, but at least in my shop that's equally my fault as much as it is the nurses.

If I've taken anything from this thread, it's that the next time I tube someone I'm going to make sure that prop is up and ready to run as soon as the tube is in. If their pressure is in the toilet, that's what pressors are for.

 

[lucid_leprechaun]

Tangentially: this has been a surprisingly enlightening look into the fact that there is a hell of a lot more variation in the way people intubate people in the ED than what I would have ever guessed.

Throwing my hat into the ring:
- Basically everyone gets 0.3mg/kg etomidate followed immediately by 1.2mg/kg roc.
- The hypotensive demented granny gets periintubation push dose neo
- The angioedema who I'm nasally fiberoptically intubating because her tongue fills her entire mouth gets lots of nebulized lido, nose dilated with increasing size nasal trumpets coated in lido gel then nasally tubed with ketamine only. I have a knife in my pocket and her neck is already prepped and marked with a sharpie.

I doubt that I'm ever going to push paralytics before sedatives as that seems potentially unfathomably cruel and even with the above examples, I really don't see how it's medically justified. If anyone has good peer reviewed data on it, I'd love to read it.

If the argument for pushing paralytics late in the RSI game is to assist with the patient bucking the vent or similar, I'd argue that the better solution is to make sure that the RN actually has post intubation sedation set up and ready to go as soon as the tube is in. Yes, that doesn't routinely happen, but at least in my shop that's equally my fault as much as it is the nurses.

If I've taken anything from this thread, it's that the next time I tube someone I'm going to make sure that prop is up and ready to run as soon as the tube is in. If their pressure is in the toilet, that's what pressors are for.

This is almost exactly what I do, glad I’m not the only one. I don’t have neo sticks so I make myself some push dose epi instead.

 

[clibby]

This is almost exactly what I do, glad I’m not the only one. I don’t have neo sticks so I make myself some push dose epi instead.

Agree except instead of a neo stick it is either an epi stick (which I can always make if I need it, it is just extra time) or I start the neo drip before RSI. I also don't have Roc at one place so I use a lot more sux or vec there.

 

[RustedFox]

This is almost exactly what I do, glad I’m not the only one. I don’t have neo sticks so I make myself some push dose epi instead.

Can... can I have neo sticks?

 

[turkeyjerky]

Can... can I have neo sticks?

I really don't understand why these aren't standard in EDs. I worked in one place where they had them, so nice. Just another bizarre example of how dysfunctional most hospitals are. They are plentiful, pre-made and already in the hospital.

The fact that some places still don't stock Rocuronium in the ED is another. Absolutely bizarre. Why do they have vec? There's basically no use for it in our practice.

 

[Arch Guillotti]

Anesthesiologist here.

Why give roc so often? Why not just use sux unless it is contraindicated?

 

[turkeyjerky]

Anesthesiologist here.

Why give roc so often? Why not just use sux unless it is contraindicated?

--most of the time we don't have access to a patient's prior medical history, thus cannot accurately determine a lack of contraindications. Plus, it's not unusual for obtunded patients to come in w/ an incidental AKI and a K of 5.9 or so. It's a form of cognitive offloading, as well as safer, to make Roc your default. Additionally, as alluded to above, Roc simplifies post-intubation vent management, allows you to get accurate measurements of Pplat and auto-PEEP and facilitates other procedures as well as imaging.

 

[thegenius]

Anesthesiologist here.

Why give roc so often? Why not just use sux unless it is contraindicated?

How often do you intubate without paralysis? Granted I'm sure the vast majority of your intubations are in the OR and you have more history and time to do things more optimally than us. But your opinion carries significant weight here. Tubing 10,000 is >>>> than my 400 times.

 

[thegenius]

Anesthesiologist here.

Why give roc so often? Why not just use sux unless it is contraindicated?

I heard from an anesthesiologist that people feel like **** when they emerge from being tubed from sux. If I recall properly.

 

[bravotwozero]

Anesthesiologist here.

Why give roc so often? Why not just use sux unless it is contraindicated?

Some of the freestanding facilities I work at don’t even have sux, only roc.

Otherwise, sux is my go to.

 

[GassYous]

I heard from an anesthesiologist that people feel like **** when they emerge from being tubed from sux. If I recall properly.

Sux causes myalgias. People give nsaids and precurarization with low dose paralytic beforehand to try to help with it

 

[Arch Guillotti]

I heard from an anesthesiologist that people feel like **** when they emerge from being tubed from sux. If I recall properly.

Just ask the other mod in the anesthesia forum. He said the myalgias were much worse than postop pain from an operation.

 

[Arch Guillotti]

How often do you intubate without paralysis? Granted I'm sure the vast majority of your intubations are in the OR and you have more history and time to do things more optimally than us. But your opinion carries significant weight here. Tubing 10,000 is >>>> than my 400 times.

The 10,000 number was tongue in cheek in reference to a regular on the anesthesia forum. Intubate with paralysis almost all the time, but not always.

 

[lucid_leprechaun]

Anesthesiologist here.

Why give roc so often? Why not just use sux unless it is contraindicated?

I mean we all know sux sucks and roc rocks so 😂

 

[WilcoWorld]

I mean we all know sux sucks and roc rocks so 😂

That's some impeccable logic

 

[Arch Guillotti]

For those who use roc and etomidate for RSI, we’re you taught to push roc before etomidate

No.