The notion of a trauma bay intubation for "pain control"

[ISoNitrous]

I had a patient for the OR (femur nail) who was intubated in the trauma bay on admission, 2 days ago, for "pain control." Had a pathological femur fracture after a mechanical fall. Young patient, presumably in their 30s. Fall was 2 days prior to surgery, still tubed.

In the trauma bay, vitals were RR48, sat 100%, BP 180s/100s, HR 80s.

Is this as senseless as I think it is? I've never heard that as an indication for intubation - curious as to what the practice is at other hospitals.

Thanks for weighing in.

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[2buckchuck]

Sounds kinda silly, not doing the patient any favors. Might be more to the story though.

 

[kidthor]

Is this as senseless as I think it is?

Yes.

I've never heard that as an indication for intubation - curious as to what the practice is at other hospitals.

It happens at other hospitals too however it’s not a valid indication for intubation.

 

[Beeftenderloin]

Is this as senseless as I think it is? I've never heard that as an indication for intubation - curious as to what the practice is at other hospitals.

Yes, it is. Why they wouldn’t just hit them with a couple hundred mcgs of fentanyl or a couple mg of dilaudid is beyond me.

 

[GassYous]

Yes, it is. Why they wouldn’t just hit them with a couple hundred mcgs of fentanyl or a couple mg of dilaudid is beyond me.

Because you'll get arrested and charged with murder probably

I'd give some narcs and do a block or something

 

[MirrorTodd]

**** throw in an epidural and get that easy dvt prophylaxis benefit. Guy ain't going anywhere with a broken femur anyway.

 

[2Fast2Des]

In med school my university hospital in the hood used to intubate the jerk hole patients who think running their mouth in the trauma bay was going to win them favors. The reasoning was airway protection\practice for delirious and combative patients presenting harm to themselves and everyone.

Although intubation for pain control...that's just dumb

 

[NitroS]

Never heard intubation for pain control.

 

[Mehd School]

Place I did surgical ICU at routinely would intubate for agitated delirium. Often times they weren't that agitated.

Nothing a few days of sedation and a new nidus for infection couldn't fix.

 

[chessknt]

What was his sedation requirement on the vent? What was given prior to the decision to intubate? Was he combative at any point? Etoh in system on arrival? There can be a lot more to the story.

 

[dabears505]

I've never heard of this before.

 

[DrOwnage]

Sometimes I wish I could intubate my wife to go hop on my x box for a couple of hours. Is that an indication? *stubs toe, self-intubates*

 

[nimbus]

In med school my university hospital in the hood used to intubate the jerk hole patients who think running their mouth in the trauma bay was going to win them favors. The reasoning was airway protection\practice for delirious and combative patients presenting harm to themselves and everyone.

Although intubation for pain control...that's just dumb

Our trauma surgeons will do a behavioral intubation for patients who won’t or can’t cooperate for their workup…ie…be aggressive with staff, spit on staff, won’t lie still in scanner, etc.

 

[Radetzky]

Intubation to get through a scanner makes sense.

Intubation for pain control makes no sense

 

[coffeebythelake]

I had a patient for the OR (femur nail) who was intubated in the trauma bay on admission, 2 days ago, for "pain control." Had a pathological femur fracture after a mechanical fall. Young patient, presumably in their 30s. Fall was 2 days prior to surgery, still tubed.

In the trauma bay, vitals were RR48, sat 100%, BP 180s/100s, HR 80s.

Is this as senseless as I think it is? I've never heard that as an indication for intubation - curious as to what the practice is at other hospitals.

Thanks for weighing in.

we've all seen crazy **** being done in the ER. Why were they tubed? and why did they remain tubed for 2 days? obv not staying in ER all that time, so the ICU team thought this was OK too? definitely funky

 

[coffeebythelake]

should cross post this in the ER forum? ;-)

 

[Status Sciaticus]

should cross post this in the ER forum? ;-)

Most definitely should. Maybe youll get some serious answers that might be worth exploring. I think theres definitely more to the story though.

 

[nimbus]

Most definitely should. Maybe youll get some serious answers that might be worth exploring. I think theres definitely more to the story though.

Yeah. Unless this is a routine for them, there must be more to the story.

 

[Beeftenderloin]

Because you'll get arrested and charged with murder probably

🤔 Healthy 30 yo is gonna need more than 1mg of vitamin D for an acute femur fracture.

 

[Shimmy8]

Also….why waiting two days? Needs to be done ASAP and get off the vent.

I believe more to story. Likely combative. Easy call if it’s a potential poly-trauma, they don’t know what’s going on, and patient is combative. If mechanism is enough for a femur fracture in a healthy 30 something, likely
to have other injuries and be concussed/combative.

 

[Status Sciaticus]

I cant imagine why anyone is waiting for a fat embolism or rhabdo to occur with a true femur fracture. Yeah theres definitely more to this story. Is the indication the patient's pain control or the providers?

 

[KetamineForAll]

I bet it was a combative patient. ED calls that one a social intubation (then they usually goose the patient)

 

[leviathan]

Makes no sense, yet we see it all the time. And i've heard comments from nurses "we can't extubate this patient, they're in too much pain." WHAT?

 

[D P356]

Sometimes I wish I could intubate my wife to go hop on my x box for a couple of hours. Is that an indication? *stubs toe, self-intubates*

Better enjoy that Xbox. That would be the last “intubation” of any kind with her for a long time.

 

[drmwvr]

Sounds like it wasn't the patient whose pain was being controlled....

 

[norski]

Better enjoy that Xbox. That would be the last “intubation” of any kind with her for a long time.

Healthy dose of oral midazolam. Duh.

 

[Ronin786]

Old school trauma docs will do that. I've seen it with rib fractures that aren't flail segments and purely painful.

It's stupid and really has no place.

 

[OTCAwesome]

Makes no sense, yet we see it all the time. And i've heard comments from nurses "we can't extubate this patient, they're in too much pain." WHAT?

Pain is an excellent stimulus to breathe

 

[Robotic Wis-Hipple]

I think ya’ll are being a bit tough on the ED guys here. New pathologic fracture you’re not jumping straight to a block or epidural as they don’t know his labs/coag status initially. He likely wouldn’t tolerate positioning anyway. Only way to get control there is a decent slug of opioid, 100mcgs isn’t gonna do it.

I’d assume a bit more to the story, maybe they needed to get a scan. Maybe it’s just easier to get pain control, attempt some kind of reduction, and get a scan if you tube em. Plus, they assume guys going to the OR in the next few hours to day anyway. Why he stayed tubed in the ICU for 2 days is weird, but again likely more to it.

 

[BobLoblaw78]

Makes about as much sense (assuming there is not more to the story) as the patients remaining intubated bc they had a surgery during call hours. I used to see that all the time. Blew my mind.

 

[IMGASMD]

Makes about as much sense (assuming there is not more to the story) as the patients remaining intubated bc they had a surgery during call hours. I used to see that all the time. Blew my mind.

Might as well just call it intubation for convenience….. whose? Mine!

Was sitting in for a 6 hour Esophagectomy recently at the very end. It was a CRNA case throughout the day. The message was, long case, “everyone” expected patient to be intubated and shipped to ICU. The surgeon had a similar case a week ago, also sent to ICU intubated.

I reviewed the records, wondered why? Before the surgeon left the room, leaving his underlings….
“You think we can extubate?”
“Patient been very stable, I was wondering why not?”

Everyone in the room, resident, pa, circulator, scrub……. All stared at me.

Patient flied. No issue, sitting up in PACU. Awake alert with some pain. Sent to ICU with a NC.

 

[drmwvr]

100mcgs isn’t gonna do it.

It will if you add some ketamine....

 

[Arch Guillotti]

Might as well just call it intubation for convenience….. whose? Mine!

Was sitting in for a 6 hour Esophagectomy recently at the very end. It was a CRNA case throughout the day. The message was, long case, “everyone” expected patient to be intubated and shipped to ICU. The surgeon had a similar case a week ago, also sent to ICU intubated.

I reviewed the records, wondered why? Before the surgeon left the room, leaving his underlings….
“You think we can extubate?”
“Patient been very stable, I was wondering why not?”

Everyone in the room, resident, pa, circulator, scrub……. All stared at me.

Patient flied. No issue, sitting up in PACU. Awake alert with some pain. Sent to ICU with a NC.

Because half of them do crappy and don’t fly at some point postop.

 

[Radetzky]

Because half of them do crappy and don’t fly at some point postop.

Are you implying that’s a reason to leave them intubated?

 

[IMGASMD]

Because half of them do crappy and don’t fly at some point postop.

Of course. But is that a reason to just assume we are packing them up to go into icu and let icu deal with it for rest of the night?

I was a hospitalists before at a smaller place. Once in a blue moon, I will have to admit/receive what I would call anesthesia dump. Not the greatest feeling.

Certainly not this case, she was scheduled to go to icu to begin with. No HD compromises, no large fluid shift, no airway difficulties, and she was intubated with a DLT. I had to exchange it for the ICU anyway. It “may” also be better for the patient in the long run. Here’s the most important part…. I was on-call overnight…. The longer I am in the room, the longer I don’t have to deal with the board.

 

[anbuitachi]

2-4mg of dilaudid and 50 of ketamine . dont need intubation

the worst is when i see young patients get intubated for whatever reason... and then they are started on like 15 of prop infusion. when they come to me in the OR, their veins are bulging and face is bright red with systolics of 200+ tachy to 140+...

 

[Dr. Rude]

Makes about as much sense (assuming there is not more to the story) as the patients remaining intubated bc they had a surgery during call hours. I used to see that all the time. Blew my mind.

After hours care is not just the same. Less staffing, often less experienced staffing, people over worked and tired. I have seen some things missed during the night that I don't think would have been missed during the day. I have left more than one patient vented that I was on the fence about because of the hour of the case.

 

[lakersbaby]

we used to do tons of trauma intubations for combative patients which made some sense to allow for trauma evaluations. pain is ridiculous.

 

[Arch Guillotti]

Was sitting in for a 6 hour Esophagectomy recently at the very end. It was a CRNA case throughout the day. The message was, long case, “everyone” expected patient to be intubated and shipped to ICU. The surgeon had a similar case a week ago, also sent to ICU intubated.

So is your beef with the CRNA sitting the case or the (presumably) anesthesiologist that was directing the case before you?

 

[Planktonmd]

In med school my university hospital in the hood used to intubate the jerk hole patients who think running their mouth in the trauma bay was going to win them favors. The reasoning was airway protection\practice for delirious and combative patients presenting harm to themselves and everyone.

Although intubation for pain control...that's just dumb

Yes, the good old "intubated for airway protection" which translates into "intubated for being a jerk".

 

[IMGASMD]

So is your beef with the CRNA sitting the case or the (presumably) anesthesiologist that was directing the case before you?

Had to think about this question for a bit.
Maybe a little of both. And also “everyone” just expect wash their hands off and go home….. well, the whole system I suppose.

CRNAs (there were 3) - beat on their chest, and we are just as good as physicians, if not better. We “care” more. We treat “patients” not diseases. We went to anesthesia school that took more training than physicians. I’ve done this with this surgeon before, it’s all the same algorithm that I follow./But it’s 5pm, peace out.

My partners - we supervise hard, but we also allow CRNAss to make some decisions, so they can feel they’re part of the team./But 1:3 is more “efficient” way to run the practice, we can’t piss too many of them off.

OR staff - we are a great team, and here to catch any safety violations that anesthesiologists/surgeons don’t follow. I have policies that says X leads to Y. Can’t you see?/Even though I am on call, I need to pick for tomorrow. So let’s send the patient to ICU, don’t waste precious OR time to wake the patient.

System - We are the best in the whole state. All these accredited agencies say so. It must be true./However, we can’t recruit because we overwork everyone, now even with overtime no one wants to stay. We need to be more “efficient.”

What does the patient need? Or what’s the best thing for the patient? Who cares, if it doesn’t fit my agenda, timeline or resources, I will still do whatever is according to my needs. I am guilt of that from time to time too.


Tl;Dr For once I have the power to grind the whole institution down to do what I believe will be the best for the patient. I will take it. Even for brief 45 mins.