Sedation for CT scan

[Quimby2]

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So the nurse brings the patient back from an incomplete head CT 'cause he's bucking like...well, like the usual drunk r/o SDH at our dear county facility here. He's s/p ativan 10mg and haldol 10 mg. Attending freak'n out about over sedating pt for CT. Sr. resident wants the guy to chew on some plastic before being sent back.

What the heck? Isn't there a better way? More haldol???? Maybe a better drug regimen?

 

[BKN]

So the nurse brings the patient back from an incomplete head CT 'cause he's bucking like...well, like the usual drunk r/o SDH at our dear county facility here. He's s/p ativan 10mg and haldol 10 mg. Attending freak'n out about over sedating pt for CT. Sr. resident wants the guy to chew on some plastic before being sent back.

What the heck? Isn't there a better way? More haldol???? Maybe a better drug regimen?

He should have been smoking the white owl before you got to 10 and 10. Think airway protection, think respiratory depression.

Only alternative ketamine.

 

[EM Junkie]

He should have been smoking the white owl before you got to 10 and 10. Think airway protection, think respiratory depression.

Only alternative ketamine.

"Smoking the white owl"???

I'm assuming that has something to do with intubation, but you're going to have to talk me through it... My post-Match fourth year brain doesn't understand!!

 

[BKN]

"Smoking the white owl"???

I'm assuming that has something to do with intubation, but you're going to have to talk me through it... My post-Match fourth year brain doesn't understand!!

Sorry, local jargon, I guess. White Owl is (was?) a cigar that comes in a white metal tube. ET tubes used to be white opaque plastic, thus a patient intubated on the vent was smoking the white owl.

The important point is you protect airways that are endangered and ventilate those who won't breathe. A intoxicated drunk is already at risk and this one has been given major sedation on top of his self administered depressant. The attending was right to be freaked. He never should have been sent to the scanner without adult supervision and a tube.

Don't sedate drunks or druggies unless:
1. they are under constant monitoring and supevision,
2. suction, O2 and intubation equipment are immediately available
3. experienced airway manager within 30 seconds

bkn

 

[southerndoc]

I like to call them "el tubos"

 

[NinerNiner999]

Someone's gonna get some PVC...

 

[drifter]

I've used very small doses of etomidate (5 mg) titrated for conscious sedation on demented/AMS patients for CTs. I got a couple of minutes of sedation - enough for a head CT but probably not much else. I've never used it with an intoxicated patient - seems a little risky. For the beligerent drunk or altered trauma patient I have had to intubate. Although, your medicine colleagues may not be very appreciative if you end up having to admit because they are too wasted to extubate.

 

[NinerNiner999]

One can always argue that altered mental status, intoxication, and suspected head injury could indicate airway protection by ETT...

 

[USCDiver]

And it's good practice.

 

[MeowMix]

"Smoking the white owl"???

Also 70s Navy slang for fellatio. Which I'm assuming is irrelevant here.

 

[EM Junkie]

Also 70s Navy slang for fellatio. Which I'm assuming is irrelevant here.

What's fellatio?

For those that don't understand the laughing smileys, I am joking....

 

[AJM]

What's fellatio?

For those that don't understand the laughing smileys, I am joking....

That question goes perfectly with your pic. I can just imagine: [high, squeaky voice] "Ummm, what's fellatio, Miss Crabaple?"

 

[AJM]

One can always argue that altered mental status, intoxication, and suspected head injury could indicate airway protection by ETT...

Out of curiosity, what's the data on intubation for "airway protection"? (the quotes probably give away my bias on the subject 🙂 ). It's my understanding that the data is pretty weak on trying to "protect" the airway on a spontaneously breathing patient who otherwise has no other indication for intubation. In fact, there is some evidence that rapid sequence induction and intubation in these patients can increase their risk of aspiration. In our MICU's we often will extubate these patients within hours (or minutes) of their arrival from the ED even if their mental status is unchanged from their initial presentation.

Now, intubation of an uncooperative/agitated patient who needs to get a procedure or diagnostic study I can definitely understand.....

 

[BKN]

Out of curiosity, what's the data on intubation for "airway protection"? (the quotes probably give away my bias on the subject 🙂 ). It's my understanding that the data is pretty weak on trying to "protect" the airway on a spontaneously breathing patient who otherwise has no other indication for intubation. In fact, there is some evidence that rapid sequence induction and intubation in these patients can increase their risk of aspiration. In our MICU's we often will extubate these patients within hours (or minutes) of their arrival from the ED even if their mental status is unchanged from their initial presentation.

Now, intubation of an uncooperative/agitated patient who needs to get a procedure or diagnostic study I can definitely understand.....

Can't give you data off the top of my head. Can tell you that back when we had to get anesthesia down to use the sux and ventilators were at a premium(late 70s), we put them on left side, head down if they were comatose and breathing. As I remember the patients (mostly ODs) vomited and aspirated often.

I doubt that anybody would do such a study today, Way outside of practice parameters. Honestly, studies are to establish things that are unclear. i don't think that this is.

 

[bartleby]

There's a reson why CT scanners are often referred to as "a cold, lonely place where patients go to die". In addition to it falling under the rubric of Bad Form, it is oh so uncomfortable to try to intubate a patient who went apneic after 20mg of haldol and 4mg of ativan on the gantry of a CT scanner after a panicked "come over here quick!" phone call from a harried radiology tech.

 

[mikecwru]

Out of curiosity, what's the data on intubation for "airway protection"? (the quotes probably give away my bias on the subject 🙂 ). It's my understanding that the data is pretty weak on trying to "protect" the airway on a spontaneously breathing patient who otherwise has no other indication for intubation. In fact, there is some evidence that rapid sequence induction and intubation in these patients can increase their risk of aspiration. In our MICU's we often will extubate these patients within hours (or minutes) of their arrival from the ED even if their mental status is unchanged from their initial presentation.

Now, intubation of an uncooperative/agitated patient who needs to get a procedure or diagnostic study I can definitely understand.....

BKN gave a more intelligent reply. I was just going to say "Hendrix, man."
mike

 

[Seaglass]

I was also interested if there is any evidence to support intubating those with AMS so I did hte following Medline searches:

("Intubation"[MeSH] OR "Intubation, Intratracheal"[MeSH]) AND airway protection
("Intubation, Intratracheal"[MeSH]) AND aspiration prevention NOT Proseal
("Intubation, Intratracheal"[MeSH]) AND "altered mental status"
("Intubation, Intratracheal"[MeSH]) AND "CNS depression"
("Intubation, Intratracheal"[MeSH]) AND "Central nervous system depression"
("Intubation, Intratracheal"[MeSH]) AND "AMS"
aspiration AND "central nervous system depression"
aspiration AND "altered mental status"
"Pneumonia, Aspiration/prevention and control"[MeSH] AND "Central Nervous System"[MeSH]
"Intubation, Intratracheal"[MeSH] AND "intoxicated"
"Intubation, Intratracheal"[MeSH] AND "intoxication"
airway AND protection AND intoxication
airway AND protection AND intoxicated
airway AND "altered mental status"
airway AND "depressed mental status"
airway AND "depressed central nervous system"
("glascow coma score" OR "GCS") AND airway
("glascow coma score" OR "GCS") AND aspiration

And got the following articles. I reviewed about 600 abstract titles for relevance. At least for now this is likely to be something that is based more on clinical experience than evidence. The best study is the last reference, #13, that was a prospective observational study evaluating GCS and the need for intubation that identified a GCS of 8 as strongly predicting the need for intubation. I suspect this is the study that our current practice is based around. There certainly weren't any better studies identified in my search. Reference #11 is interesting. In a study of drunks, the amount of drunkeness was not predictive of developing aspiration pneumonia. In the GCS and airway reflexes study, GCS was not correlated with the presence or absence of a gag. Interesting stuff. I really need to get my hands on the article in citation #13. I suspect there may be more references there.

Comments?

Items 1 - 7 of 7
1: Rudolph SJ, Landsverk BK, Freeman ML. Related Articles, Books, LinkOut
Endotracheal intubation for airway protection during endoscopy for severe upper GI hemorrhage.
Gastrointest Endosc. 2003 Jan;57(1):58-61.
PMID: 12518132 [PubMed - indexed for MEDLINE]

2: Mercer MH. Related Articles, Books, LinkOut
An assessment of protection of the airway from aspiration of oropharyngeal contents using the Combitube airway.
Resuscitation. 2001 Nov;51(2):135-8.
PMID: 11718968 [PubMed - indexed for MEDLINE]

3: Paventi S, Liturri S, Colio B, Santevecchi A, Ranieri R. Related Articles, Books, LinkOut
Airway management with the Combitube during anaesthesia and in an emergency.
Resuscitation. 2001 Nov;51(2):129-33. Retraction in: Paventi S, Liturri S, Santevecchi A, Ranieri R. Resuscitation. 2002 Sep;54(3):317.
PMID: 11718967 [PubMed - indexed for MEDLINE]

4: Tayal VS, Riggs RW, Marx JA, Tomaszewski CA, Schneider RE. Related Articles, Books, LinkOut
Rapid-sequence intubation at an emergency medicine residency: success rate and adverse events during a two-year period.
Acad Emerg Med. 1999 Jan;6(1):31-7.
PMID: 9928974 [PubMed - indexed for MEDLINE]

5: Asai T. Related Articles, Books, LinkOut
Editorial II: Who is at increased risk of pulmonary aspiration?
Br J Anaesth. 2004 Oct;93(4):497-500. No abstract available.
PMID: 15361474 [PubMed - indexed for MEDLINE]

6: Oswalt JL, Hedges JR, Soifer BE, Lowe DK. Related Articles, Books, LinkOut
Analysis of trauma intubations.
Am J Emerg Med. 1992 Nov;10(6):511-4.
PMID: 1388374 [PubMed - indexed for MEDLINE]

7: Redding JS, Tabeling BB, Parham AM. Related Articles, Books, LinkOut
Airway management in patients with central nervous system depression.
JACEP. 1978 Nov;7(11):401-3.
PMID: 45681 [PubMed - indexed for MEDLINE]

8: Michael H, Harrison M. Related Articles, Links
Best evidence topic report: endotracheal intubation in gamma-hydroxybutyric acid intoxication and overdose.
Emerg Med J. 2005 Jan;22(1):43. Review.
PMID: 15611542 [PubMed - indexed for MEDLINE]

9: Vadeboncoeur TF, Davis DP, Ochs M, Poste JC, Hoyt DB, Vilke GM. Related Articles, Links
The ability of paramedics to predict aspiration in patients undergoing prehospital rapid sequence intubation.
J Emerg Med. 2006 Feb;30(2):131-6.
PMID: 16567245 [PubMed - in process]

10: Davis DP, Vadeboncoeur TF, Ochs M, Poste JC, Vilke GM, Hoyt DB. Related Articles, Links
The association between field Glasgow Coma Scale score and outcome in patients undergoing paramedic rapid sequence intubation.
J Emerg Med. 2005 Nov;29(4):391-7.
PMID: 16243194 [PubMed - indexed for MEDLINE]

11: Christensen MA, Janson S, Seago JA. Related Articles, Links
Alcohol, head injury, and pulmonary complications.
J Neurosci Nurs. 2001 Aug;33(4):184-9.
PMID: 11497070 [PubMed - indexed for MEDLINE]

12: Moulton C, Pennycook AG. Related Articles, Links
Relation between Glasgow coma score and cough reflex.
Lancet. 1994 May 21;343(8908):1261-2.
PMID: 7910279 [PubMed - indexed for MEDLINE]

13: Chan B, Gaudry P, Grattan-Smith TM, McNeil R. Related Articles, Links
The use of Glasgow Coma Scale in poisoning.
J Emerg Med. 1993 Sep-Oct;11(5):579-82.
PMID: 8308236 [PubMed - indexed for MEDLINE]

 

[BKN]

Out of curiosity, what's the data on intubation for "airway protection"? (the quotes probably give away my bias on the subject 🙂 ). It's my understanding that the data is pretty weak on trying to "protect" the airway on a spontaneously breathing patient who otherwise has no other indication for intubation. In fact, there is some evidence that rapid sequence induction and intubation in these patients can increase their risk of aspiration. In our MICU's we often will extubate these patients within hours (or minutes) of their arrival from the ED even if their mental status is unchanged from their initial presentation.

Now, intubation of an uncooperative/agitated patient who needs to get a procedure or diagnostic study I can definitely understand.....

I think I know what you're getting at. It's the OD who's up and down depending on the amount of stimulus he gets. And boy, there is no stimulus like a tube in your trachea. When I've got this kind of patient, I used to just pull the tube out. The problem was that as soon as you did that, they went down again. I've only had one aspiration in an intubated patient in thirty years. Whe I bronched him through the tube it was like a starless night, charcoal everywhere.

But I've had lots of patients who I wish that I had intubated earlier. They didn't all make it. So now my policy is if I'm not sure, the get tubed. I'll even go ahead and sedate them if the tube agitates them until they metabolize whatever s__t they took. sounds ridiculous. When they get to the unit, they may have changed.

In any case, do the study. I await the results with interest. I've often been wrong before. 😀

 

[Seaglass]

BTW, How's it going AJM.

 

[ER-ER-Oh]

So the nurse brings the patient back from an incomplete head CT 'cause he's bucking like...well, like the usual drunk r/o SDH at our dear county facility here. He's s/p ativan 10mg and haldol 10 mg. Attending freak'n out about over sedating pt for CT. Sr. resident wants the guy to chew on some plastic before being sent back.

What the heck? Isn't there a better way? More haldol???? Maybe a better drug regimen?

Unless there's a high suspicion for closed head injury based on history or physical exam I wouldn't sedate, intubate, or anything else. I'd do 1/2 hour neuro checks and wait a little. Doing CT's on random drunks without good reason just leads you down a path that can cause more problems than solutions.

 

[Seaglass]

Unless there's a high suspicion for closed head injury based on history or physical exam I wouldn't sedate, intubate, or anything else. I'd do 1/2 hour neuro checks and wait a little. Doing CT's on random drunks without good reason just leads you down a path that can cause more problems than solutions.

That is also the general practice at my institution. If they are not waking up in an appropriate amount of time then we go looking for things.

 

[The White Coat Investor]

I'd be freaking too, not because you sedated him, but because he got so much sedation (10 mg of Ativan and 10 mg of Haldol.) I usually try a mg or two or Ativan, maybe 5 of Haldol, then I start thinking tube.

 

[takotsubo]

Do you guys ever intubate someone in the ED (drunk or wahtever) and do scans and workup and then extubate IN the ED?

 

[BADMD]

Do you guys ever intubate someone in the ED (drunk or wahtever) and do scans and workup and then extubate IN the ED?

If you are intubating them for medical necessity, then doing a work up, and then extubating because the clinical picture has changed and they now no longer need intubation, that is fine.

If you are intubating them so that you can provide deep sedation for your work up, then allow them to wake up and extube, then you should make sure you have anesthesia privileges.

 

[WilcoWorld]

If you are intubating them for medical necessity, then doing a work up, and then extubating because the clinical picture has changed and they now no longer need intubation, that is fine.

If you are intubating them so that you can provide deep sedation for your work up, then allow them to wake up and extube, then you should make sure you have anesthesia privileges.

Are you saying that we should be able to make this distinction prospectively, or that we should be careful to document our medical decision making with this in mind?

 

[BADMD]

Are you saying that we should be able to make this distinction prospectively, or that we should be careful to document our medical decision making with this in mind?

I'm saying do what it right for the patient and if you want to do something that is essentially what an anesthesiologist does, then call one.

 

[WilcoWorld]

And I'm saying that sometimes one can't tell if a patient needs to be intubated "for medical necessity" until after the work-up is done, a work-up that couldn't be done safely until the patient was intubated and sedated.

 

[Rendar5]

And I'm saying that sometimes one can't tell if a patient needs to be intubated "for medical necessity" until after the work-up is done, a work-up that couldn't be done safely until the patient was intubated and sedated.

Ended up having this done on a GHB intoxicated patient. Had to be helicoptered in and had unknown ingestion at the time and was deeply sedated. Intubated in field because they didn' tknow what was going on. She woke up on me but was agitated so we knocked her out finished teh workup, then when were sure that there were no major causes for her initial presentation, woke her up and extubated.

 

[takotsubo]

Ended up having this done on a GHB intoxicated patient. Had to be helicoptered in and had unknown ingestion at the time and was deeply sedated. Intubated in field because they didn' tknow what was going on. She woke up on me but was agitated so we knocked her out finished teh workup, then when were sure that there were no major causes for her initial presentation, woke her up and extubated.

I've never extubated someone in the ED before, what are some of the criteria that you look for to determine their readiness?

 

[WilcoWorld]

I've never extubated someone in the ED before, what are some of the criteria that you look for to determine their readiness?

I prefer not to extubate in the ED, as it's fraught with difficulties and requires a level of nursing that we can't really spare. However, if the work-up has been negative, the vitals are stable, and the patient is breathing over the vent with good respiratory effort/tidal volumes/saturations then I'll consider extubating in the ED if there are no beds in the ICU and the patient's just going to be sitting downstairs for hours.

 

[Old_Mil]

So the nurse brings the patient back from an incomplete head CT 'cause he's bucking like...well, like the usual drunk r/o SDH at our dear county facility here. He's s/p ativan 10mg and haldol 10 mg. Attending freak'n out about over sedating pt for CT. Sr. resident wants the guy to chew on some plastic before being sent back.

What the heck? Isn't there a better way? More haldol???? Maybe a better drug regimen?

Intubate, Ventilate, Sedate, Irradiate.

 

[docB]

I'm saying do what it right for the patient and if you want to do something that is essentially what an anesthesiologist does, then call one.

We don't have anesthesia on call tot he ED. They tend not to be too excited about taking care of the uninsured tox and trauma patients who are the main consumers of "behavioral intubation" anyway.

 

[spyderdoc]

I agree. We can hardly even get the gas passers to come in and do a blood patch on a well insured pt, never mind an agitated drunk no-pay.

We don't have anesthesia on call tot he ED. They tend not to be too excited about taking care of the uninsured tox and trauma patients who are the main consumers of "behavioral intubation" anyway.

 

[mlw47]

Scott Weingart over at the EMCrit Blog just did a great piece on ED extubations.

http://blog.emcrit.org/podcasts/extubation/


In general, the material on the site is top notch, and if you're not a regular follower, I'd suggest it.

http://blog.emcrit.org/podcasts/



*No disclosures to report.

 

[EMRAGE]

I've never extubated someone in the ED before, what are some of the criteria that you look for to determine their readiness?

FiO2 30% with great sats, awake enough to follow commands, cuff leak and breathing over the vent = safe extubation.

Rarely done in the ED. Once they're tubed they can be expedited to the ICU where internist and critical care specialist can concern themselves with the more mundane... I have other drunks to take care of.😕

RAGE

 

[Rendar5]

I've never extubated someone in the ED before, what are some of the criteria that you look for to determine their readiness?

I had a recent unexpected case again a week or so ago. polypharmic OD, guy came in completely apneic. 5 hours later, after ICU admission (required for all vented pt's in my institute), pt's waking up in the ED. So we wait until he's able to breath on his own at a decent rate, and can fully follow commands without signs of agitation before extubating him in ED. He ends up going to a stepdown unit for close observation in case he zonks out again, but leaves ED without a tube.

 

[pinipig523]

What I like to do for quick sedation for CT.. but this is only for 1 minute plain brains - I don't have a great cocktail for 10 minute knock-outs without tubing the guy.

2 morphine
2 versed

Try it. I do it when the guy is on the table. I start with the 2 of morphine. Then the 1 of versed. If the guy is still mobile, give the last 1 of versed and 90% of the time, the guy is amenable for a plain brain. Tape his head to the table and usually you're done.

If you have to do more than that though, chances are - you need to make the guy eat some plastic before your next repeat trip to the CT suite. It's too risky.

 

[yahoomail]

So the nurse brings the patient back from an incomplete head CT 'cause he's bucking like...well, like the usual drunk r/o SDH at our dear county facility here. He's s/p ativan 10mg and haldol 10 mg. Attending freak'n out about over sedating pt for CT. Sr. resident wants the guy to chew on some plastic before being sent back.

What the heck? Isn't there a better way? More haldol???? Maybe a better drug regimen?

Good old Etomidate, minimal cardiovascular depression, excellent sedation, quick onset and short duration of action - almost ideal for short procedures like CT scan.