Intubation and the unconscious

[E tank]

Etomidate has a known adrenal suppressive effect and at this point probably the only reason you have a pressure of 100 systolic is a last-ditch catecholamine dump. Blunt that with etomidate and that turns into a bad day quickly.

A single dose of etomidate does not effect peri-induction/intubation adrenal function. The association with adrenal insufficiency affecting outcome is controversial in specific patient groups. I give etomidate to intubate unstable patients all day, every day.

 

[Bullets]

Good afternoon everyone,
Im a newer paramedic and have a question about intubation.
ill start it off with a brief scenario to summarize my question.

Non-RSI agency responds 78 year old female found unresponsive in her bed, radial pulses are present with a GCS of 1,2,2.
SPO2 reads 80% despite ventilatory support with BVM and OPA and 100% FiO2 by BLS. Sinus Tachycardia 140, BP 100/80. Lung sounds diffuse rhonchi bilaterally without wheezing or signs of pulmonary edema / JVD

Can I take out the OPA and place an ET tube without the use of etomidate prior because the patient is unconscious without a gag reflex or does etomidate have to be pushed prior to the intubation attempt. just having a hard time summing this one up.

Hoping for some positive educational responses, I know this might be a dumb question but want the best success for my patients!

Honestly, long before i got to advanced airway management i would swap the regular BVM mask with a CPAP mask and ventillate myself to assess compliance and possiby get an end tidal and waveform. Elevate her head and get her into a better position for eventual intubation. I would also want to be aggressive with fluid resusictation and pressure control in preparation for eventual intubation. Bilateral lines with fluid running, getting a pressor of your choice and in this case i would go with phenlyepherine given her rate. Once we get her pulse ox up and ideally pressures up, then we would go with the intubation attempt. Depending on how she responds to our previous efforts determine if i even use medication. Theres a possibility that a patient with a GCS of 5 doest even need MFI.

 

[MackTheKnife]

Good afternoon everyone,
Im a newer paramedic and have a question about intubation.
ill start it off with a brief scenario to summarize my question.

Non-RSI agency responds 78 year old female found unresponsive in her bed, radial pulses are present with a GCS of 1,2,2.
SPO2 reads 80% despite ventilatory support with BVM and OPA and 100% FiO2 by BLS. Sinus Tachycardia 140, BP 100/80. Lung sounds diffuse rhonchi bilaterally without wheezing or signs of pulmonary edema / JVD

Can I take out the OPA and place an ET tube without the use of etomidate prior because the patient is unconscious without a gag reflex or does etomidate have to be pushed prior to the intubation attempt. just having a hard time summing this one up.

Hoping for some positive educational responses, I know this might be a dumb question but want the best success for my patients!

Read all of the other replies. She is in ARDS, no gag reflex, and her sats are in the toilet. Intubate her, period. {edited}. No need for etomidate, versed, or paralytics.

 

[MackTheKnife]

Honestly, long before i got to advanced airway management i would swap the regular BVM mask with a CPAP mask and ventillate myself to assess compliance and possiby get an end tidal and waveform. Elevate her head and get her into a better position for eventual intubation. I would also want to be aggressive with fluid resusictation and pressure control in preparation for eventual intubation. Bilateral lines with fluid running, getting a pressor of your choice and in this case i would go with phenlyepherine given her rate. Once we get her pulse ox up and ideally pressures up, then we would go with the intubation attempt. Depending on how she responds to our previous efforts determine if i even use medication. Theres a possibility that a patient with a GCS of 5 doest even need MFI.

Sats are 80% despite Fi02 of 100% and you're talking "eventual intubation"? Seriously?

 

[E tank]

She is in ARDS

How do you know that?

 

[Akulahawk]

Good afternoon everyone,
Im a newer paramedic and have a question about intubation.
ill start it off with a brief scenario to summarize my question.

Non-RSI agency responds 78 year old female found unresponsive in her bed, radial pulses are present with a GCS of 1,2,2.
SPO2 reads 80% despite ventilatory support with BVM and OPA and 100% FiO2 by BLS. Sinus Tachycardia 140, BP 100/80. Lung sounds diffuse rhonchi bilaterally without wheezing or signs of pulmonary edema / JVD

Can I take out the OPA and place an ET tube without the use of etomidate prior because the patient is unconscious without a gag reflex or does etomidate have to be pushed prior to the intubation attempt. just having a hard time summing this one up.

Hoping for some positive educational responses, I know this might be a dumb question but want the best success for my patients!

If you're certain you can place the tube quickly and gently, you certainly could intubate without pushing the Etomidate. There's certainly a danger in vagal stimulation from the attempt so that's something to consider. That being said, this patient is already down enough to the point where there's no gag reflex and is (apparently) taking PPV... remember, she's a GCS 5, it's not a far drop to GCS 3. With this patient, I probably wouldn't do RSI or MAI because they're already basically sedated enough.

I suspect that since you're already considering pushing Etomidate, you've got at least one IV line... I'd say get some fluids going, get to the truck, drop the tube quickly, have a pressor ready (whatever your protocol calls for) and be ready to sedate if she begins to wake. Speedy but gentle (IMO) would be the order of the day.

In any event, this is one of those kinds of patients that you don't want to spend a whole lot of time messing around with on scene. What would you do as an EMT with a patient like that and NO immediately available ALS unit? Start with that and do your interventions en-route to the hospital. You should have all your "stuff" more readily available in the ambulance anyway, so... if she crashes (or tries to) en-route, you're already that much closer to definitive care than you'd be if you were still on scene.

 

[DrParasite]

Can I take out the OPA and place an ET tube without the use of etomidate prior because the patient is unconscious without a gag reflex or does etomidate have to be pushed prior to the intubation attempt. just having a hard time summing this one up.

Can you? who knows... here is a question: why do you want to?

are you not getting good compliance with the BVM? having trouble getting a seal around her face? lots of visible gastric distention? yeah, the SPO2 kinda sucks, but can you fix that without intubating? could you manage this patient appropriately with a BIAD and an NG tube?

don't get me wrong, I'm not saying don't intubate or RSI her, but what is the reason you want to do it, when you have other options? esp when doing so exposes to her to potential negative side effects?

 

[StCEMT]

Sats are 80% despite Fi02 of 100% and you're talking "eventual intubation"? Seriously?

In the sense of I am going to do some prep work first before jumping in with a laryngoscope, absolutely.

 

[Carlos Danger]

Good afternoon everyone,
Im a newer paramedic and have a question about intubation.
ill start it off with a brief scenario to summarize my question.

Non-RSI agency responds 78 year old female found unresponsive in her bed, radial pulses are present with a GCS of 1,2,2.
SPO2 reads 80% despite ventilatory support with BVM and OPA and 100% FiO2 by BLS. Sinus Tachycardia 140, BP 100/80. Lung sounds diffuse rhonchi bilaterally without wheezing or signs of pulmonary edema / JVD

Can I take out the OPA and place an ET tube without the use of etomidate prior because the patient is unconscious without a gag reflex or does etomidate have to be pushed prior to the intubation attempt. just having a hard time summing this one up.

Hoping for some positive educational responses, I know this might be a dumb question but want the best success for my patients!

To get right to what I suspect is the main thrust of your question: no, an obtunded patient in extremis does not require sedation prior to intubation. This is often termed a “crash intubation” and the goal is just to get the ETT in place ASAP and deal with everything else after. Also, as others have said, a patient like the one you describe could potentially deteriorate precipitously with even a small dose of hypnotic.

However, if you are going to attempt to intubate, your chances of success are significantly enhanced with relaxation. Just because a patient accepts an OPA doesn’t mean that they are going to cooperate with you shoving a semi-rigid piece of plastic down their trachea. Some succinylcholine would be cheap insurance and present virtually no downsides.

 

[NomadicMedic]

To get right to what I suspect is the main thrust of your question: no, an obtunded patient in extremis does not require sedation prior to intubation. This is often termed a “crash intubation” and the goal is just to get the ETT in place ASAP and deal with everything else after. Also, as others have said, a patient like the one you describe could potentially deteriorate precipitously with even a small dose of hypnotic.

However, if you are going to attempt to intubate, your chances of success are significantly enhanced with relaxation. Just because a patient accepts an OPA doesn’t mean that they are going to cooperate with you shoving a semi-rigid piece of plastic down their trachea. Some succinylcholine would be cheap insurance and present virtually no downsides.

This guy doesn’t have paralytic agents. So, sucks to be him. With no succs.

 

[coolidge]

This isn't a real patient, just a scenario that I played out in my head. Threw a soft pressure in there for reassurance that a tube can be placed when chemical intervention is limited and contraindicated. I don't think lidocaine is in our standing orders but can be wrong (will have to follow up on that) Lets say I did go ahead and pass the tube without chemical and her blood pressure stabilized, we do have a protocol for post intubation management; 5mg versed every 10 minutes (as needed) with 100mcg loading dose of fentanyl followed by 50mcg every 5 minutes. I would assume because she has a pulse we would continue with pain management for this patient and if needed repeated doses of sedation.
Just want validation thank you for your response.

Noted cardiac is sinus tachycardia (REG) with noted rate above. Thinking in terms of straight respiratory pathology over cardiac.

50 mcg every 5 minutes?

 

[MrBrown]

Brown has had a good noggin scratch over this one.

The most significant abnormality in her vital signs is her profound hypoxaemia. If she has diffuse rhonchi when you listen to her lungs, then there is obviously some sort of mechanical obstruction to gas exchange such as foreign material (for example, vomit) or fluid (for example, blood or pulmonary oedema fluid). I use the term mechanical to differentiate it from a biochemical cause; for example, monoxyhaemoglobin binding or something of that nature. In this case, in theory, I suspect there will lbe no clinically significant difference between good basic oxygenation and ventilation with, for example, an LMA and intubation.. Certainly, an endotracheal tube has less leak than, for example, an ventilation with a bag and mask or LMA, but I dno not think the amount will be clinically significant. The same analogy applies as to say giving 100% oxygen does not increase oxygen delivery to an ischaemic myocardium because it cannot pass the occluded artery. If there is something interfering with gas exchange then changing from something else to an endotracheal tube will not fix that problem.

As to your question .... it surprises me nobody has looked at the facts overall. The most obvious being: how far away is the hospital and can it do what this lady needs? If a hospital that can secure her airway, do at least basic investigations to see what might be going on, and provide basic intensive care (ventilation at least) is close by (less than say, 20 minutes by road), then personally, I would just keep up basic airway manoeuvers and take her to hospital. If the hospital is far away, or the local hospital cannot do these things, then it is more sensible to look at securing her airway more definitively on scene.

You raise an interesting proposition of just giving her a general anaesthetic and making her unconscious without neuromuscular blockade. I accept that in many operating theatres around the world every hour of every day, many patients are simply made unconscious and have their airway looked after, perhaps including with an endotracheal tube, without neuromuscular blockade. This may even be clinically suitable for some patients seen by ambos. I must, however, question the logic in doing that. If you are going to do something, do it bloody properly. I do not see the point of doing things by half measures. particularly in the "general" type of patients seen by ambulance personnel who tend to be more unwell than your average person requiring elective general anaesthesia. I am sure I do not need to state the obvious disadvantages of laryngoscopy for intubation, particularly on someone with a traumatic brain injury, without neurmuscular blockade. Whatever medicine of flavour you can choose I suppose .... although I do not see a great benefit in simply using suxamethonium. I accept in most operating theatres, elective anaesthesia uses suxamethonium, but again, I think it common ground the type of patients seen by ambulance personnel are different enough that a long acting medicine (for example, rocuronium) is more preferable. That said, I accept there may be the odd patient who is actively dying and needs an airway immediately, more immediately than taking the time to set up for full sequence anaesthetic and intubation. The example I can think of is someone with rapidly worsening pharyngeal oedema or something. I suppose in that situation with a choice between quickly making them unconscious or being faced with an obstructed airway you cannot pass an endotracheal tube through, that is the exception. I have not obviously discussed the patient in cardiac arrest as that changes clinical priorities quite somewhat.

Hope that is as helpful for you as it was interesting for me.

 

[Carlos Danger]

Brown has had a good noggin scratch over this one.

The most significant abnormality in her vital signs is her profound hypoxaemia. If she has diffuse rhonchi when you listen to her lungs, then there is obviously some sort of mechanical obstruction to gas exchange such as foreign material (for example, vomit) or fluid (for example, blood or pulmonary oedema fluid). I use the term mechanical to differentiate it from a biochemical cause; for example, monoxyhaemoglobin binding or something of that nature. In this case, in theory, I suspect there will lbe no clinically significant difference between good basic oxygenation and ventilation with, for example, an LMA and intubation.. Certainly, an endotracheal tube has less leak than, for example, an ventilation with a bag and mask or LMA, but I dno not think the amount will be clinically significant. The same analogy applies as to say giving 100% oxygen does not increase oxygen delivery to an ischaemic myocardium because it cannot pass the occluded artery. If there is something interfering with gas exchange then changing from something else to an endotracheal tube will not fix that problem.

ET tubes have several advantages over SGA's, one of which is the ability to use higher airways pressures and PEEP to prevent or resolve atelectasis and overcome whatever pressure gradient (hydrostatic or otherwise) is resulting in pulmonary edema. In fact, increasing airway pressure is usually the very next step in improving oxygenation when normalizing minute volume and increasing Fi02 doesn't work. This can be done with CPAP in an awake and cooperative patient, but an ETT and mechanical ventilation is often the best option.

I am a big fan of SGA's in general and especially for EMS, but we can't pretend that ETT's aren't much better in some circumstances. If something is interfering with gas exchange, then depending on what exactly it is, switching to a ETT may be very beneficial.

 

[DrParasite]

As to your question .... it surprises me nobody has looked at the facts overall. The most obvious being: how far away is the hospital and can it do what this lady needs? If a hospital that can secure her airway, do at least basic investigations to see what might be going on, and provide basic intensive care (ventilation at least) is close by (less than say, 20 minutes by road), then personally, I would just keep up basic airway maneuvers and take her to hospital. If the hospital is far away, or the local hospital cannot do these things, then it is more sensible to look at securing her airway more definitively on scene.

Why does this matter? Does the distance from a hospital affect a paramedics scope of practice? So prehospital provider not treat a patient appropriately, if they are X minutes from a hospital, so the hospital can do it?

Don't misunderstand me, if it's a complicated procedure that a provider is uncomfortable doing (surgical airways, dopamine drips, weird OB things), I'm all for waiting and letting the ER do it, provided the patient is being maintained adequately. But intubation is a "relatively" simple skill, one that should be practiced on real patients (when appropriate), to ensure basic competency is maintained.

Last I heard, proximity to the ER was not an acceptable reason for a paramedic to not do their job; if that was the case, than there would be no paramedics within a 20 minute drive to every ER, and just a BLS ambulance to take them to the hospital and let the ER do what needs to be done.

 

[Akulahawk]

Certainly, an endotracheal tube has less leak than, for example, an ventilation with a bag and mask or LMA

Precisely because an ETT has less leak than the BVM or LMA, you can run higher peak pressures. Obviously one must be careful not to cause barotrauma.

If a hospital that can secure her airway, do at least basic investigations to see what might be going on, and provide basic intensive care (ventilation at least) is close by (less than say, 20 minutes by road), then personally, I would just keep up basic airway manoeuvers and take her to hospital. If the hospital is far away, or the local hospital cannot do these things, then it is more sensible to look at securing her airway more definitively on scene

It appears to me that time to a hospital determines the level of care that may be provided to a patient. When I was an active field provider, I looked at what level of care the patient required and how I could best deliver that care to the patient. If my patient requires immediate tracheal intubation, it doesn't matter if I'm across the street or 20 minutes down the road - that patient is getting an ETT. Not intubating the patient can delay definitive care by several minutes precisely because the equipment to do so at the hospital takes a couple minutes (or more) to retrieve and set up even if there's a crash cart in the room. If the hospital has sufficient notification, then perhaps they can get their airway/RSI kit set up before the patient arrives.

 

[MrBrown]

Well said mate, Brown agrees with you wholeheartedly.

Also .... suxamethonium. Because no post from Brown is complete without saying suxamethonium, it's like Brown's second favourite word

 

[StCEMT]

Why does this matter? Does the distance from a hospital affect a paramedics scope of practice? So prehospital provider not treat a patient appropriately, if they are X minutes from a hospital, so the hospital can do it?

Don't misunderstand me, if it's a complicated procedure that a provider is uncomfortable doing (surgical airways, dopamine drips, weird OB things), I'm all for waiting and letting the ER do it, provided the patient is being maintained adequately. But intubation is a "relatively" simple skill, one that should be practiced on real patients (when appropriate), to ensure basic competency is maintained.

Last I heard, proximity to the ER was not an acceptable reason for a paramedic to not do their job; if that was the case, than there would be no paramedics within a 20 minute drive to every ER, and just a BLS ambulance to take them to the hospital and let the ER do what needs to be done.

Honestly, more of a side point then anything.... I'd argue that a cric or pressor drip is no more difficult nor something we should put off if it's warranted. I programmed pumps for my main job to streamline and simplify the initiation of pressors. Now its as simple as put the amount on the screen in the bag on the screen and run it within the limits I've set.