Scenario-ish: To intubate or not to intubate?

[STXmedic]

@Remi Just to pick your brain, what is your rationale behind Etomidate over Ketamine here? Not arguing- genuinely curious.

 

[Carlos Danger]

S/s of increasing ICP/multisystem trauma with airway compromise = buying plastic.

I don't think you did anything terribly wrong, but i will have to disagree with you and the other posters and say that this guy needed intubation.

It should take you about one minute.

This is dinosaur thinking, guys. The idea that these patients benefit from early prehospital intubation has been soundly disproven by research, and should (and is, slowly) go the way of backboards.

This patient needed airway management, not necessarily intubation. Aggressive does not always equal appropriate.

Edit: I'm not saying that intubating patients like this is necessarily wrong.....I'm saying that it's definitely not the definition of progressive care.

@Remi Just to pick your brain, what is your rationale behind Etomidate over Ketamine here? Not arguing- genuinely curious.

Well, it's just my own experience and bias, I guess. I know that ketamine has been shown safe in increased ICP states, but in a patient like this, I'm more comfortable using an agent that I know reduces ICP, maintains CBF, and raises the seizure threshold.

If they were hypotensive, ketamine would probably be my first choice, but with hypertension and signs of herniation, I guess I'm just not sold on it.

 

[STXmedic]

Thanks. I guess being relatively new to ketamine, and being accustomed to my wife telling me about her numerous patients who actually receive ketamine blouses for IICP in the NSICU, I'm not having to fight that old stigma. I hadn't considered etomidate's effect on seizure activity, though.

 

[medicsb]

What meds would I have used if I'd have tubed this guy? A large dose of etomidate quickly followed by some sux would work just fine. I'd prefer propofol over etomidate, but most of us don't have that in the field....etomidate is just fine; so is ketamine if it's all you have, though it'd be my last choice. If I had time, I'd cut the dose of etomidate in half, and give some lidocaine, fentanyl, esmolol, and glycopyrrolate (or a small dose of atropine) first.

Lidocaine? Esmolol? Glycopyrrolate? WHHHYYYYY? None of that stuff has any evidence of improved outcomes and just takes up time. The patient is also hemodynamically unstable (HR 40s-90s). Keep the beta-blockers far away. Keep anything that could decrease HR or blood pressure far away. This pt. was in an MVC, we do not know if the CNS is the only system involved; they still have significant potential for internal bleeding.

This is dinosaur thinking, guys. The idea that these patients benefit from early prehospital intubation has been soundly disproven by research, and should (and is, slowly) go the way of backboards.

Except it has not really been disproved. Afterall, the best airway study to date demonstrated improved functional outcomes. But then again that study is hard to extrapolate to the US where training and experience in most places are so much less than Australian MICA Paramedics. It's probably more realistic to say that poorly trained and/or inexperienced intubators (i.e. the overwhelming majority of US paramedics) are associated with poor outcomes.

 

[CANMAN]

Given your situation, resources on hand, location, and time to the trauma center I think the care you provided was completely appropriate and glad to see provider's making the smart choice. With the being said, held to the protocols within my system (which is an RSI system and Paramedic/Nurse team) I would be looking for a new job if I didn't intubate a trauma scene patient with a GCS of 3.

My question would be if the car really had over two feet of intrusion to the seat/patient compartment how the hell were you able to peel the door back and rapidly extricate? Given the details and damage to the seat one would think the door, rocker channel, etc would be mangled...?

 

[SandpitMedic]

I wasn't the one who said "He's buying a tube on arrival" or something to that, and the ER tube is cake in comparison. But, I feel like I want to comment on that.

While I am not cavalier with my airway, I am aggressive. I am always cognizant of my patient's ability to tolerate a tube, and of their probable projected clinical course. I.e: Should I tube this 69 year old COPD'er she may never come off of the vent. CPAP is an option to avoid a 3 month ICU admission vs. a 3 day observation in MedTele. Of course, with a patient like this- trauma/brain injury... The ET tube is the only definitive choice AND it is what this patient requires.

I trained, practiced, and prepared for that, be it a difficult or an "easy" tube. I'm a paramedic. That is why intubation is in my scope. And if it is warranted and indicated, barring other contraindications, I will almost always do it. I've had patients that go downhill with less invasive and patients that improve with less invasive. But a trauma patient with no gag and posturing is getting it.

Suffice it to say, there is also nothing wrong with going the route of Robb. He wasn't "wrong" It's okay not to tube... Due to time, adequate BLS, equipment malfunction, contraindications, etc.

So long as you are acting in your patients best interest you did the right thing.

You won't get every tube, and you don't always need to. There is always the BLS/ILS option. Additionally, and fortunately I have the option of direct and video laryngoscopy, that helps also.

And who is "missing" all these tubes... It's almost 2015.... Continuous waveform capnography anyone? You have to try to not know you're not in...

 

[teedubbyaw]

Next person to say cavalier gets slapped.

 

[DesertMedic66]

Next person to say cavalier gets slapped.

Cavalier

 

[triemal04]

Based only on the available information, it really only depends on one thing.

Are you (and this isn't meant in a personal way, but something that to many people don't really understand and think about) truly competant at intubation and equipped to do so? Which includes everything that comes before, and after the act of placing a tube in the trachea.

If the answer is yes, then he should have been intubated. If the answer is no, (and there's no shame in that) then he shouldn't have been, and what you did was fine.

 

[Carlos Danger]

Lidocaine? Esmolol? Glycopyrrolate? WHHHYYYYY? None of that stuff has any evidence of improved outcomes and just takes up time. The patient is also hemodynamically unstable (HR 40s-90s). Keep the beta-blockers far away. Keep anything that could decrease HR or blood pressure far away. This pt. was in an MVC, we do not know if the CNS is the only system involved; they still have significant potential for internal bleeding.

We don't know for sure that the CNS is the only system involved, but we know for sure that it is involved that that preventing further injury to it is a high priority. I think there is plenty of evidence that prevention of secondary injury due to hypertension or hypotension is beneficial.

The goal of these drugs is to improve hemodynamic stability by reducing anesthetic requirements while also blunting the ICP increase that follows laryngoscopy and intubation. Even if other injuries do exist, I don't see how pursuit of more stable hemodynamics would be harmful.

A perfect induction and intubation in a patient like this means zero change in MAP and ICP, so getting as close to that as possible is the idea.

• Lidocaine reduces anesthetic requirements, meaning you can use less sedation. It also may prevent ectopy, and it blunts ICP increases. Yes, I know that last one is controversial. I still use it on most intubations, whether emergent or not.

• Glyco prevents bradycardia in the face of spikes in ICP, esmolol, sux, and opioids. I have actually begun using glyco as a routine pre-medication for most of my anesthetics.

• Esmolol also reduces anesthetic requirements, and prevents spikes in BP. A small dose is not going to cause hypotension, but it will go a long ways towards preventing the hypertension that results from airway instrumentation. I give a lot of esmolol to sick patients.

• You can use fentanyl as a sympatholytic, but to do that reliably requires pretty high doses (>3 mcg/kg), which in combination with other anesthetics can contribute to undesirable decreases in MAP.

• Etomidate --> sux --> tube is a perfectly acceptable strategy if those drugs are all you have, or if they are all you know how to use, or if the patient is crashing. There is plenty to be said for the K.I.S.S principle in the field or in a crisis. But Robb asked what we'd like to use, and given the chance I like to try doing a little better than the very basics.

Except it has not really been disproved. Afterall, the best airway study to date demonstrated improved functional outcomes. But then again that study is hard to extrapolate to the US where training and experience in most places are so much less than Australian MICA Paramedics. It's probably more realistic to say that poorly trained and/or inexperienced intubators (i.e. the overwhelming majority of US paramedics) are associated with poor outcomes.

The vast majority of studies on intubation by American paramedics show high rates of complications and worsened or unimproved outcomes. Does it have to be that way, or will it always be that way? Of course not, and I hope not. But it's been like that for decades and the trend does not appear to be changing, at least not from what I can see.

 

[medicsb]

We don't know for sure that the CNS is the only system involved, but we know for sure that it is involved that that preventing further injury to it is a high priority. I think there is plenty of evidence that prevention of secondary injury due to hypertension or hypotension is beneficial.

The goal of these drugs is to improve hemodynamic stability by reducing anesthetic requirements while also blunting the ICP increase that follows laryngoscopy and intubation. Even if other injuries do exist, I don't see how pursuit of more stable hemodynamics would be harmful.

But, in light of the fact that injuries were sustained in an MVC, you cannot proceed as if the CNS is the only affected organ system. In the prehospital setting and in the ED, you plan as if other organ systems are affected. They are a multi-system trauma until proven otherwise. In this pt., I would argue that one should proceed as if they did have ongoing, uncontrolled bleeding - consider them hypovolemic even if they are not showing outward signs of shock or compensation thereof. I certainly do not have the time to mull over research on the use of some extravagant RSI cocktail, but just a brief skimming of results on pubmed of the different agents suggest seems to show retrospective studies on patients for which the diagnosis has already been made in which the outcomes are based on surrogate outcomes (hemodynamic parameters versus actual patient outcome). In EM/EMS/CCM, etc., we already have learned in the past that improvement in surrogate end-points do not always equal improvement in outcomes.

A perfect induction and intubation in a patient like this means zero change in MAP and ICP, so getting as close to that as possible is the idea.

• Lidocaine reduces anesthetic requirements, meaning you can use less sedation. It also may prevent ectopy, and it blunts ICP increases. Yes, I know that last one is controversial. I still use it on most intubations, whether emergent or not.

If the patient makes it to the OR without already being intubated, chances are you know a lot more about them than the person intubating in the field or the ED. Regardless, prevention of ectopy - who cares? We don't even care about ectopy in patients having an MI, why care if they are under anesthesia (I facepalmed everytime I saw an anesthesia provider push lidocaine just because the patient threw a few PVCs). Less anesthetic requirement is good given the effects it can have on hemodynamics, but its not like lidocaine doesn't have its own potential problems. At this time, there are no data demonstrating improvement in patient centered outcomes. You are most likely treating the monitor and yourself more than anything. Keep the lido in the drug box.

• Glyco prevents bradycardia in the face of spikes in ICP, esmolol, sux, and opioids. I have actually begun using glyco as a routine pre-medication for most of my anesthetics.

Sounds like you're more likely to be treating the effects of meds you're giving than the patient. Worried about bradycardia? Hold the esmolol.

• Esmolol also reduces anesthetic requirements, and prevents spikes in BP. A small dose is not going to cause hypotension, but it will go a long ways towards preventing the hypertension that results from airway instrumentation. I give a lot of esmolol to sick patients.

Any patient centered outcome data in traumatic brain injury or in a head injured patient that also has other injuries? A small dose in the patient in compensated shock may turn it to decompensated when you blunt their physiologic compensatory mechanism (i.e. incr. inotropy and HR). The otherwise healthy patient without concomitant injury may do just fine, but the scenario does not provide you with that patient. Hypotension is far more devastating to the head injured patient, so why add an agent that is more likely to decrease BP than anything else?

• You can use fentanyl as a sympatholytic, but to do that reliably requires pretty high doses (>3 mcg/kg), which in combination with other anesthetics can contribute to undesirable decreases in MAP.

You provided all the reasons why it probably is not necessary in the scenario provided.

• Etomidate --> sux --> tube is a perfectly acceptable strategy if those drugs are all you have, or if they are all you know how to use, or if the patient is crashing. There is plenty to be said for the K.I.S.S principle in the field or in a crisis. But Robb asked what we'd like to use, and given the chance I like to try doing a little better than the very basics.

Sometimes the very basics are what's best. I would say that etomidate and succs is probably no worse than the cocktail suggested and may be better.

 

[RocketMedic]

I'd say that this patient needed a tube. With that being said, not necessarily an EMS tube if you really are only seven minutes out.

 

[Akulahawk]

Pretty much what RM above said. This patient needs a tube/definitive airway control. EMS doesn't have to be this patient's intubationist though. I do agree with the idea of using a bridge device like an LMA though. They can be about as fast to deploy as a King Tube and if you have the right kind, you can intubate through it or you can use a bougie and drop a tube that way. When you're just 7 minutes out and the patient looks pretty much like crap and getting worse, sometimes it's just best to "think" like an EMT and scoop & run and do your ALS stuff, whatever you can, while en-route. If I have a couple of extra bodies, I'll grab 'em and put 'em to work... and if I have time to drop a tube, then I'll do it. Sometimes it's just better to use a BLS airway for now and take definitive airway control later. I think this is just on of those cases. Besides, with a decent report, it should be obvious to the ED that they may be the ones to intubate and they'll be ready & waiting to do it upon arrival.

Something else to remember is that if you have a vent, you might be able to set that up to be "the bag" for you so all someone has to do is maintain a good seal. Just a thought and hopefully EMS vents can be used in that way.

 

[RocketMedic]

A king plus a vent could be a great thing. With that being said, a hit hard enough to cause dysrhythmias probably devastated cerebral perfusion, so I wouldn't be super-optimistic as to mortality. This guy needs a neurosurgeon and Doc Brown's Delorean.

 

[RocketMedic]

Also depends a lot on the patient to be tubed. Robb's better at tubes than I am, but I think we all agree that a mallapatti one is a way easier tube than a superobese 4+.

 

[Carlos Danger]

Sometimes the very basics are what's best.

Yep, sometimes KISS is best, as I already said. And sometimes it's not.

Look, maybe you are unfamiliar with glyco and esmolol as adjuncts to intubation, but they are commonly used drugs that help to stabilize hemodynamics. Small-moderate doses of esmolol do not cause hypotension or bradycardia, especially in the face of SNS discharge.

All it amounts to is giving normal induction meds, along with a couple adjuncts that allow you to use smaller doses of hemodynamically compromising drugs and to blunt the negative physiologic response to the procedure. Nothing overly complicated about it.

I'll give you that there's no research that shows my "cocktail" is better than etomidate + sux, but there is plenty of research that tells us how bad hypotension and hypertension is for these patients, and I can assure you that you'll see much less dramatic swings in MAP when you use these adjuncts properly. So take that equation for whatever it's worth to you.

 

[SeeNoMore]

I would intubate en route, RSI meds as needed.

 

[systemet]

The patient's oxygenating well, appears to be ventilating ok, and is 7 minutes from a trauma center with real doctors. You've got to draw up your ket, sux, and 1:100 epi, prep your tube, get out a bougie, prep a King or LMA, grab out the cric kit, fire an end-tidal on the bagger, and maybe setup the vent. You can do this in 7 minutes, but when they're sat'ing high, and not seizing, I'd hold off and keep with the BVM/OPA. I'm a fairly good paramedic, but the EM guys are a lot better at this than me.

Put the patient a little further away, make them difficult to bag, hypoxic, give them some chest wall injuries, or change the nature of the receiving facility and this decision changes.

I wouldn't put a King or LMA in this patient without drugs. They may be a 3, but they've postured, have hemodynamics but are altered, and probably have a significant closed head injury. I agree that there may be other occult injuries.

If I was going to tube them, I'd go with a half-dose of ketamine, and sux. I don't have lidocaine any more. I've read a few of the studies, and agree that there's no positive outcome data, but I like the physiological argument that increasing ICP is bad, and premedication with lido decreases ICP spikes in bolted patients getting deep suction in the ICU. If I had access to it, I would give it. I don't see a massive downside.

Regarding glyco'/atropine and esmolol, I wouldn't give either. I understand that these things might be used in the neuro ICU or OR once the patient's been thoroughly irradiated, but I'd be concerned about other injuries that might not have delcared themselves. I don't carry esmolol on my ambulance, and am not comfortable with using it for premedication. I do use metoprolol occasionally for rate control.

 

[SeeNoMore]

I am surprised how many folks would opt not to intubate this patient. That being said I am used to working with a partner, if I was alone in the back drawing up meds and maintaining the airway would be more challenging. Though I would intubate this patient, I would not question a medic who chose to maintain the airway with a BVM or other device. It just goes against the stereotype of Paramedics being quick to intubate. I guess EMTlife (hopefully) represents a more thoughtful community of providers given everyone here has interest in the exchange of ideas outside of the workplace at a minimum.

 

[RocketMedic]

It's not that he doesn't need to be intubated, it's a realization that intubation is not the be-all of his care.