# Judgment call:  When do you decide to intubate an unconscious drunk person?



## abckidsmom (Dec 13, 2010)

Scenario for discussion's sake:

You're called for a 20 yof in the local college dorms.  You get there to find what had been a rollicking good time, lots of empty beverages, lots of tipsy girls.  They called for their friend who has passed out.  She is unresponsive to verbal stimuli, but stirs and moans a little when you move her out of the bathroom.

VS:  
HR- 78
BP- 112/74
RR- 14, breath sounds clear
SpO2- 98% RA

The roommate, who came home to find all this mess and has not been joining the party, says that she has no medical problems that she's aware of, takes no medications, and has no allergies that she's aware of.

How are you going to manage this patient, assuming that alcohol intoxication is her only problem?


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## ebass30920 (Dec 13, 2010)

I work in a college town and we rarely intubate this type of pt.  The only ETOH pt. I can remember getting a field intubation from my crew was a regular we who often had blood alcohol in like .400s regularly. (he hold the unofficial ED record at .533 if I remember correctly).  Granted we are also about 10 min out from the hospital.  Usually we sit them up with and emesis basin and suction as needed.  Maybe some of them need it but it just doesnt seem to happen very often.


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## Flight-LP (Dec 13, 2010)

Just as we have all been taught. Keep it very basic.

Is the airway patent? If she starts vomiting in an altered state or is unable to control her tongue thus impeding the airway, she needs to be intubated. 

If she can maintain her own airway, set her up in a fowlers position, give her some oxygen as needed, and take her to the ER.


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## Shishkabob (Dec 13, 2010)

If they have been / are actively vomiting, I'd push up the point to where I'd decide.  However, I also have access to NG/ OG tubes so I'd probably place one to suction the stomach.  Do pretty much anything I can to stave off intubation.


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## abckidsmom (Dec 13, 2010)

Flight-LP said:


> Just as we have all been taught. Keep it very basic.
> 
> Is the airway patent? If she starts vomiting in an altered state or is unable to control her tongue thus impeding the airway, she needs to be intubated.
> 
> If she can maintain her own airway, set her up in a fowlers position, give her some oxygen as needed, and take her to the ER.



Some colleagues disagree, so I'm going to dig in here a little.  Would you really want to wait till she *starts* vomiting to intubate her?  What are you looking for to see whether she can maintain her own airway before she's actually aspirating vomit?


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## Flight-LP (Dec 13, 2010)

abckidsmom said:


> Some colleagues disagree, so I'm going to dig in here a little.  Would you really want to wait till she *starts* vomiting to intubate her?  What are you looking for to see whether she can maintain her own airway before she's actually aspirating vomit?



Well, first and foremost, what is the initial presentation? Is she snoring? Is there equal movement and quality to her respirations? Do these items correct with manual opening of the airway? If present and uncorrected, then they get intubated.

 After identification of the aformentioned presenting signs, the glossopharyngeal and vagus cranial nerves are the next items I check. Remember that us humans lack a rigid structure supporting the hyoid bone. As such, if the voluntary muscle support is lacking and the patient cannot swallow, they cannot maintain their airway. Thus, they will be intubated. Same goes for the gag, if it is not present or is diminished, they get intubated.

If we are o.k. up to this point, then they get some oxygen via mask. Attached to that mask will be an ETCO detector which will provide waveform capnography. Is the wave disorganized without discernable plateau? If so, it could be indicative of a partial obstruction.

I am also fortunate to have access to a volume / flow measuring pneumotach. By monitoring the airway pressures, we can continuously watch for an impending obstruction by the tongue and/or epiglottis.

It is definately a judgement call, but I have no hesitation to definitively control the airway if immediately needed or anticipated. You are correct in your statement though, if they are already blowing out the beer and pizza, chances are you are already behind the 8 ball.


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## firetender (Dec 13, 2010)

*What is NOW?*

You came up with drunk as a diagnosis
VS stable
Airway clear
No indications of anything life-threatening on board
*
Why in heaven's name would you even consider administering an Invasive Procedure?* 

_*Intubation is NOT without many hazards, least of which would be stimulating the gag reflex of a drunk. Under the stated circumstances you'd be setting the patient up for further damage because you're working with what you fear rather than what is presenting to you.
*_
So your narrative is incomplete; of course there are more factors, but based on what you said I think it's real important to remember to work with what IS and that doesn't sound like what you were thinking.

This is not directed at you, but look at it this way:

If you don't have confidence in your being able to first anticipate and then respond to the onset of vomiting by positioning the patient and manually, if necessary (got gloves? suction?) keep the patient's airway clear, then what makes you think you'd have the skills or confidence to get an E.T. tube properly placed on someone NOT in clear and present danger and VERY likely to regain consciousness during your attempt?


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## DrParasite (Dec 14, 2010)

abckidsmom said:


> You're called for a 20 yof in the local college dorms.  You get there to find what had been a rollicking good time, lots of empty beverages, lots of tipsy girls.  They called for their friend who has passed out.  She is unresponsive to verbal stimuli, but stirs and moans a little when you move her out of the bathroom.


So she isn't unresponsive; she is responsive to painful stimuli.  can you arouse her to opening eyes and talking at all?


abckidsmom said:


> VS:
> HR- 78
> BP- 112/74
> RR- 14, breath sounds clear
> SpO2- 98% RA


vitals sound good





abckidsmom said:


> The roommate, who came home to find all this mess and has not been joining the party, says that she has no medical problems that she's aware of, takes no medications, and has no allergies that she's aware of.
> 
> How are you going to manage this patient, assuming that alcohol intoxication is her only problem?


Monitor and transport her to the hospital, ensure she can maintain her own airway, and if she can't, or if she loses a gag reflex,  OPA and BVM with possible intubation?  but probably avoid intubating, at least as long as she is maintaining her own airway.


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## abckidsmom (Dec 14, 2010)

Flight-LP said:


> Well, first and foremost, what is the initial presentation? Is she snoring? Is there equal movement and quality to her respirations? Do these items correct with manual opening of the airway? If present and uncorrected, then they get intubated.
> 
> After identification of the aformentioned presenting signs, the glossopharyngeal and vagus cranial nerves are the next items I check. Remember that us humans lack a rigid structure supporting the hyoid bone. As such, if the voluntary muscle support is lacking and the patient cannot swallow, they cannot maintain their airway. Thus, they will be intubated. Same goes for the gag, if it is not present or is diminished, they get intubated.
> 
> ...




Thanks for this detailed thought process.   It's helpful to hear something with organization and facts.

The people I'm dealing with are very free with their RSI.  Since it's a judgment call, and it comes down to the beer and pizza factor, there is very little actual control from the powers that be in the situation.  This is extremely helpful conversation, though.


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## abckidsmom (Dec 14, 2010)

firetender said:


> You came up with drunk as a diagnosis
> VS stable
> Airway clear
> No indications of anything life-threatening on board
> ...



Forgot to throw in the RSI, sorry.  This is a system where all the medics can RSI.

Yours is the song I sing when I talk to these people, and this discussion is in preparation for a CME session on the risks of intubation beyond the chance of failing to control the airway properly.  

Nasty as it is, after a little judgment and assessment, I'm typically the one to watch the airway and deal with the vomiting if it comes, but if they're already puking, that makes me more likely to intubate.  Still not a guarantee.  

I think a key is that she rouses to stimulus.  Not all the way, not to coherence, but she rouses.  I don't think that drunks need intubation necessarily, just when they present with an unmanagable airway.


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## usalsfyre (Dec 14, 2010)

firetender said:


> You came up with drunk as a diagnosis
> VS stable
> Airway clear
> No indications of anything life-threatening on board
> ...



Because there are a few people who get so obtunded from "just" alcohol (which can certainly be life-threatening itself) that they truly require airway protection. Talk to any major medical center near a university and you'll find they treat some honest to God alcohol poisonings every year that end up in ICU, either from the alcohol or resultant aspiration pneumonias. 

That said,  it's a big, black line to cross and you can be darn sure I've tried everything else before we start trying to intubate this girl, with the assistance of drugs or otherwise. 99% of these patients get by just fine with a little suction, proper positioning and maybe an NPA and supplemental O2. Flight-LP posted an excellent checklist on things to evaluate before breaking out the laryngoscope.


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## FFMedic75 (Dec 16, 2010)

A good rule of thumb is if you have impending airway compromise they need to be intubated.  This is a call only the medic on scene can make.  A good physical exam like Flight-LP listed will get you pointed in the right direction.  You also may want to consider if there were other drugs involved.  This may lead you in the intubate direction a little more quickly.  As far as RSI, the process isn't the difficult part.  Give some weight dependent drugs and intubate, hopefully every medic on the planet is capable of doing that.  The difficult part is having the knowledge and clinical judgment to understand when it is indicated, which agents are indicated and how best to maintain the patient afterward.  If you are going to walk in the ER having RSI'd a drunk person you better be prepared to justify your actions.


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## jakeparamedic (Dec 22, 2010)

It all depends on if her airway is open, and patent. I understand she is unconcious, but as long as she can breath on her own, no sense in making it more difficult than what it is, we took a drunk pt into the ER once and the doctor had asked why she hadn't been intubated because she was unresponsive, we told him she was breathing fine, and her sats were at 97 room air. He then took her into one of the rooms where he tried to intubate her but she ended up throwing up, which she then aspirated, causing now, a huge airway emergency, Keep basic if you can, let them breath on their own.


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## rhan101277 (Dec 22, 2010)

In a breathing patient who you fear will stop breathing or airway impending issues you can also use nasal intubation.  We have endotrol tubes for that with a little ring on them to help guide towards trachea.  You hook up the stethoscope to it and give it a shot.


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## Dave 52-4 (Dec 22, 2010)

Hi - new here, but, being this is my first post I will keep it short.

With the VS's the OP originally put out and taking into consideration the auscultated lung fields were clear, I would place the patient on their side (facing the student or cop if riding.) 

Blow by 0ZZZ couldn't hurt, fire up the Zoll basic leads, maybe a lock. Other then that this rodeo is fairly simple. If the patient has ingested another substances you will see it by monitoring your patient, you have IV access......

What this kiddo needs is a Banana Bag, not a tube.

Me? Nope I would not be pushing an ALS2 by grabbing the Sucs and Rock here. That is just me, many have other opinions and protocols for that matter, and that is a good deal.


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## Veneficus (Dec 23, 2010)

With the information given, I would not be thinking to intubate this pt. 

She sounds intoxicated, but usually the only drunks I see who get intubated are combative.

I would also give some thought before choosing to intubate on whether or not the ED will accept the responsibility to monitor and extubate. Some won't. 

Whether or not she needs an ICU will be decided in the ED, with more information, but it looks like "no" to me from what you presented.

Assuming of course no prior significant medical history is discovered, and the only findings from the lab are ETOH. 

If she was so drunk that she was completely unconscious and unarousable, I think we would be discussing what might be wrong with her rather than if we should intubate. 

Just my thoughts.


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## slb862 (Dec 23, 2010)

Unresponsive drunk person, only to painful stimulation, lets not forget to check the blood sugar and possible some Narcan.  You never know...and if you carry and use it _maybe_ some Romazicon.  Maybe a little anti-nausea...whichever you carry.  Turn your pt. on their side, And most definately, IV fluids, hook them to the heart monitor, a little O2 (if you want). Keep your suction ready. 
AND don't forget to get mommy and/or daddy's home phone number so the ED can call someone sober to come and pick them up (the best time to call is 0300) and they can drive how many hours to come and take them home.  Plus that way mommy and daddy can see what their hard earned insurance is really paying for.  

Sorry had to get that off my chest.


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## EMSLaw (Dec 23, 2010)

slb862 said:


> Unresponsive drunk person, only to painful stimulation, lets not forget to check the blood sugar and possible some Narcan.  You never know...and if you carry and use it _maybe_ some Romazicon.  Maybe a little anti-nausea...whichever you carry.  Turn your pt. on their side, And most definately, IV fluids, hook them to the heart monitor, a little O2 (if you want). Keep your suction ready.



I'm with you on the BGL - that's probably part of the standard assessment if its within a provider's scope of practice.  Where you're losing me is the Narcan.  

There is nothing at the scene as given to indicate that the patient is suffering from an opioid overdose.  Her vitals signs are not indicative of that either, and she seems, at the moment, to be adequately respiring and oxygenating.  Assuming that we titrate Narcan to maintain respiratory drive, why would you give it here?  And hasn't the idea of the unconscious cocktail been pretty much kyboshed at this point?


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## reaper (Dec 23, 2010)

Hell, with the Narcan. That I could handle. 

But, pushing Romazicon just for the what if? That is why I am so glad it has been removed from most services!


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## alphatrauma (Dec 23, 2010)

*with the information you provided...*



abckidsmom said:


> When do you decide to intubate an unconscious drunk person?



... more than likely, never.


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## Veneficus (Dec 23, 2010)

Just in case this post was not sarcastic.



slb862 said:


> Unresponsive drunk person, only to painful stimulation, lets not for get to check the blood sugar and possible some Narcan.  You never know...



If you are going for a coma cocktail, I sincerely hope you have some thiamine with you.




slb862 said:


> and if you carry and use it _maybe_ some Romazicon.



Absolutely not. 

Romazicon, while a reversal agent is not benign. Infact it has so much adverse potential, it is just better to ventilate until the benzo wears off unless there is some mitigating factor for doing that.



slb862 said:


> Maybe a little anti-nausea...whichever you carry



Zofran, maybe.

Promethazine will likely just depress her further, so I don't think I could advocate that either.

Sometime in pharm I was once taught that all medications are poisons. If you are going to poison somebody, it needs to be done with some care, with a benefit over risk, and not anymore than required to achieve that. 

Otherwise you turn a simple drunk person into a ATP depleted causing neuro deficits and cardiac issues, degrade the GCS further likely facilitating a vent and its complications, wipe out the ability to sedate/stop a seizure with the lesser of two medications, (then your option is a barbiturate like thiopental) which is definately buying an ICU stay, not only causing more harm to the patient, but driving up the economic waste too.



slb862 said:


> AND don't forget to get mommy and/or daddy's home phone number so the ED can call someone sober to come and pick them up (the best time to call is 0300) and they can drive how many hours to come and take them home. Plus that way mommy and daddy can see what their hard earned insurance is really paying for.



Yea, just make sure she is still a minor first or you will be in breach of patient confidentiality and you and your organization will be paying for her education through medical school.

I might also mention that punishing or torturing patients is generally considered worthy of revocation of priviledges to practice.

All of that, for a drunk college kid, a scenario played out all over the world everyday? Way too much effort and headache.


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## thegreypilgrim (Dec 24, 2010)

Based just on the info you presented - that is, if I were reasonably sure she hadn't vomited and that she didn't take anything aside from alcohol - intubation wouldn't be on my mind at all.

In fact I'd be more on board with transporting to a sobering center if I were permitted to as opposed to the ED.


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## slb862 (Dec 24, 2010)

Working both EMS and Emergency Department, in a college town, I have taken care of and seen this type of pt. many a time while working.  Maybe I misunderstood, I was taught any time you have an unresponsive, (unknown), ETOH involved...you check the blood sugar, narcan -(cuz you never know what could have been slipped in that drink or what they may have taken), IV - fluids for the dehydration, HM - cuz you are not going to take any chances other "drugs" could be on board, and transport to a local hospital.
As for the Romazicon, I should have clarified it is given in the ED, (ordered by the doctor). OOPS!  
And for calling the parents, you bet I do, when working in the ED.  Whether they are under the age of 18 or any age for that matter (and in college or not), yes we do call a parent if need be.  (Most times that is the only number they can rattle off).  Do I give them pt. information, or why they are in the ED, or any personal medical information?  No I don't, I am calling to make sure the Intoxicated pt. has a sober ride and someone sober to keep an eye on them for the rest of the night.  (maybe I was a little sacrastic.)
Most of your intoxicated college students have spent the night drinking with their friends, guess what, either they don't answer the phone or they themselves are to intoxicated to drive and pick them up.  -_-


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## EMSLaw (Dec 24, 2010)

Veneficus said:


> All of that, for a drunk college kid, a scenario played out all over the world everyday? Way too much effort and headache.



This.  

The circumstances vary here, too.  If the patient has had so much to drink that they have fallen into a coma, then intubation might be indicated.  But if this is the kind of call where the patient has drunk themself into a pretty bad stupor, but has no airway compromise, and just needs to be observed, then you have a totally different situation. 

Of course, where you need to really start worrying is if the patient has had any sort of trauma.  TBI vs. ETOH is almost impossible to determine in the field, and I've heard very persuasive arguments that such a patient should go to a trauma center.  Who will probably say, "Why did you bring us a drunk?"  Which is probably what the case will be, but better that than a patient with a subarachnoid hemorrhage dying in observation at your local general hospital.


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## clibb (Dec 24, 2010)

Flight-LP said:


> Just as we have all been taught. Keep it very basic.
> 
> Is the airway patent? If she starts vomiting in an altered state or is unable to control her tongue thus impeding the airway, she needs to be intubated.
> 
> If she can maintain her own airway, set her up in a fowlers position, give her some oxygen as needed, and take her to the ER.



You wouldn't put her in the recovery position in case she all the sudden starts vomiting? Just wondering.


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## MrBrown (Dec 24, 2010)

Brown would be barely inclined to take her to the hospital, recovery position, words with the cops to clear out all the drunks, sober room-mate to leave her with and thats that.


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## Flight-LP (Dec 24, 2010)

clibb said:


> You wouldn't put her in the recovery position in case she all the sudden starts vomiting? Just wondering.



If she can maintain her own airway (as described before), then no. Should she start to vomit, then we reassess the situation (i.e. an ongoing assessment).


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