Airway Management and Intubating without Drugs

Remi

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Then again, there is at least one study out there that says emergent intubation without NMB correlates to an increase in complications as well as morbidity/mortality..
If you are really comparing apples to apples, I don't see how that could be true.

I mean, if you are talking about slipping a tube into a patient who is perfectly relaxed after getting some sux vs. one of those scenarios where one person is holding the patient's arms down and another is holding their chest and head down and they are biting your blade as you try repeatedly to ram a tube into their trachea, then sure, I can certainly see how the former would probably end up with fewer complications, and likely doing better.

But assuming the patient is relaxed enough to DL without NMB, I can't see any advantage to giving NMB just for the heck of it.
 

FiremanMike

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If you are really comparing apples to apples, I don't see how that could be true.

I mean, if you are talking about slipping a tube into a patient who is perfectly relaxed after getting some sux vs. one of those scenarios where one person is holding the patient's arms down and another is holding their chest and head down and they are biting your blade as you try repeatedly to ram a tube into their trachea, then sure, I can certainly see how the former would probably end up with fewer complications, and likely doing better.

But assuming the patient is relaxed enough to DL without NMB, I can't see any advantage to giving NMB just for the heck of it.
My feeling is that it has to do with our ability to truly assess how deeply sedated they are.. "Hey, they seem to accept an oral airway, lets cram a laryngoscope in there" only to find that the deeper stimulation led to gagging, spasms, vomiting, aspiration, etc etc..

This is echoed in that study that showed a 15% increased incidence of aspiration in the sedation only cohort and does make logical sense when I run it through my brain.. The study is admittedly small, but 15% is still 10 patients out of 67 who aspirated which would have likely been prevented with NMB..

I'm a bit fried from microbio right now, I'll do some more google searching tomorrow to see if I can find a larger study supporting NMB in emergent airways..
 

DesertMedic66

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My flight company also has the viewpoint that sedation only RSI comes with an increased risk of vomiting and aspiration.
 

Tigger

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My flight company also has the viewpoint that sedation only RSI comes with an increased risk of vomiting and aspiration.
Which is I suppose conceivable (and likely makes for more difficult intubating conditions due to potential residual muscle tone), but does the near-apneic, peri-arrest patient with a GCS of three need sedation?
 

StCEMT

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Which is I suppose conceivable (and likely makes for more difficult intubating conditions due to potential residual muscle tone), but does the near-apneic, peri-arrest patient with a GCS of three need sedation?
How often are we realistically intubating people that we need to do an abbreviated method for though? The last Roc only intubation I saw I honestly don't agree with, but less so because of sedation and more because I think there should have been a more aggressive resus first.
 

Remi

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My feeling is that it has to do with our ability to truly assess how deeply sedated they are.. "Hey, they seem to accept an oral airway, lets cram a laryngoscope in there" only to find that the deeper stimulation led to gagging, spasms, vomiting, aspiration, etc etc..

This is echoed in that study that showed a 15% increased incidence of aspiration in the sedation only cohort and does make logical sense when I run it through my brain.. The study is admittedly small, but 15% is still 10 patients out of 67 who aspirated which would have likely been prevented with NMB..

I'm a bit fried from microbio right now, I'll do some more google searching tomorrow to see if I can find a larger study supporting NMB in emergent airways..
There have actually been quite a few studies showing that using NMB increases success rates and minimizes complications with intubation.

You certainly can get NMB-like intubating conditions with sedation alone. I assure you that with enough propofol and fentanyl, you would never be to able to tell clinically whether someone was just well-sedated or paralyzed.

In actual practice however, there's usually nothing to be gained from avoiding NMB, because if you use enough sedation, you have abolished airway reflexes and induced apnea anyway. So we use sux or roc and less sedation for what they refer to in anesthesia circles as a "balanced anesthetic", and it's usually the best approach in an emergent scenario.

So it's really an academic debate: clinically, 99% of the time, just use the NMB (unless you are doing an awake intubation, which is a whole other discussion). But technically, no you don't need NMB, and if these studies were truly comparing apples to apples (meaning an ADEQUATELY sedated patient vs. one who got NMB), I think you'd see similar outcomes.
 

Tigger

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How often are we realistically intubating people that we need to do an abbreviated method for though? The last Roc only intubation I saw I honestly don't agree with, but less so because of sedation and more because I think there should have been a more aggressive resus first.
That also have a pulse? Probably not often, but I'm not sure that "if they have a pulse they get RSIed" is good practice either.
 

NomadicMedic

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Somebody should share these studies with the PA medical advisory committee. We still have sedation only intubation in our protocol.

We (our agency) doesn't allow it
.
 

FiremanMike

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Somebody should share these studies with the PA medical advisory committee. We still have sedation only intubation in our protocol.

We (our agency) doesn't allow it
.
I remember the days of Etomidate and Versed.. Etomidate at 0.3mg/kg but with a max dose of 20mg, half our people clamped down almost immediately. The fix, at the time, was doubling the Etomidate dose (it worked)..
 

RocketMedic

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What affect does NMB have on periarrest patients though? Since we’re paralyzing everything, wouldn’t any remaining vascular tone also be obliterated by nmb?
 

StCEMT

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That also have a pulse? Probably not often, but I'm not sure that "if they have a pulse they get RSIed" is good practice either.
What kind of concerns did you have in mind? Or are you thinking more of the poor hemodynamic patient being given the same dose of sedation as the relatively healthy person?
 

Remi

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What affect does NMB have on periarrest patients though? Since we’re paralyzing everything, wouldn’t any remaining vascular tone also be obliterated by nmb?
No. NMB does not affect smooth muscle.
 

Peak

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No. NMB does not affect smooth muscle.
Technically some NMBDs do have a very small effect on muscarinic receptors in smooth muscle. That being said they effect is so small it shouldn't present any appreciable change in vascular tone.
 

Remi

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Technically some NMBDs do have a very small effect on muscarinic receptors in smooth muscle. That being said they effect is so small it shouldn't present any appreciable change in vascular tone.
Only succinylcholine has muscarinic effects, but it does not cause any vasodilation because not enough of it reaches the M3 receptors to have a clinical effect, and M3 stimulation does not reliably cause vasodilation....it also causes vasoconstriction.
 

KingCountyMedic

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Those of you that have RSI drugs, what do you use on your CPR patients when they're fresh? (pulseless but still agonal, trismus etc.)

We just use Succinylcholine, never had a problem but we are looking at going to mostly Rocuronium.
 

StCEMT

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Those of you that have RSI drugs, what do you use on your CPR patients when they're fresh? (pulseless but still agonal, trismus etc.)

We just use Succinylcholine, never had a problem but we are looking at going to mostly Rocuronium.
I've never gone straight to ETI in an arrest that quickly and usually they've been down for a while by the time I get there. The most recent arrest that occurred in front of me probably would have had no issue taking a tube right away.
 

Remi

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Those of you that have RSI drugs, what do you use on your CPR patients when they're fresh? (pulseless but still agonal, trismus etc.)

We just use Succinylcholine, never had a problem but we are looking at going to mostly Rocuronium.
“Never had a problem with our current routine but can’t resist fixing what ain’t broke”.
 

rescue1

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What exactly are people's concerns with "over RSI-ing" patients who have ambiguously intact airway reflexes? Is it hypotension? Oversedation?


Regardless of what meds, if any, you are pushing in an alive patient, you should be extremely cognizant of the patients blood pressure and resuscitate them (fluids, push dose pressors) up above 90-100 systolic at the absolute minimum before even thinking about intubation, because just the act of passing the tube and ventilating is going to drop their pressure from the vagal response and potentially a preload drop from the ventilation itself. I don't think trying to avoid sedation or paralysis for fear of this is going to fix the issue, plus its pretty inhumane to not at least sedate alive patients who are getting plastic shoved down their throat. You can always give them more epi to bring them back up after the RSI meds go in.
 

KingCountyMedic

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“Never had a problem with our current routine but can’t resist fixing what ain’t broke”.

The Thomas Splint from WWI was still in use in King County up until a few years ago! Lol

We currently carry Sux & Roc but a few departments are dropping Anectine and only carrying Rocuronium. We’re going through a lot of changes, when our Mentor Dr. C left it created a weird new world. Lots of non M1 out of state Doctors coming into our system. Could be good, could be not so good.
 
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