Forcing the Tube

[Paramagic]

I think tubing the patient was appropriate; I think that 'forcing' the tube is grossly inappropriate, and I think that not giving sedation and pain relief post intubation is criminal.

[hatelilpeepees]

I have to disagree somewhat, stating up front that it is hard to tell without actually seeing the patient. This is a respiratory arrest secondary to COPD. This is not a patient who is going to get a breathing treatment and go home, she probably got sedated in the ER, put on a vent, and was sent to the ICU to die. Securing her airway via intubation is essential to properly oxygenate her lungs, forcibly expand her lungs with ventilation, and protect her airway from vomitus. Yes she will probably die anyway, but letting vomit in her lungs will definitely seal the deal.

Although it is great to ask questions in this forum, one of the best ways I have found to learn if my treatment is right or wrong, is to follow up on the patient with the hospital staff, and watch what the ER Doc does.

So I would ask, what did the ER staff do for this patient ? Not using sedation before and after was wrong.

Edited October 20, 2011 by hatelilpeepees

[BlueSkies]

Bieber I personally think you are on the right track. Sounds to me that you are progressing well as a young practitioner. I always wanted my students and new medics to ask these types of questions. Why do we do this and why do we do that? If we only follow what is written and never quesion the rationale then we are doomed to only be mediocre at best and mediocre in this field is absolutely unacceptable.

I agree with the others who have voiced their opinions about the Captain's decision to withhold sedation after the airway has already been secured. That to me is pretty counterproductive. You also have to consider the fact that her gagging on the ETT will cause her ICP to rise. With all of her health issues I am sure that HTN is in the mix and if it isn't it soon will be. I understand that this isn't a head injury case but knowing that she has health issues why take the chance on something else going wrong in the process.

I come from a service where RSI was a key aspect of our care. Coming from a flight service we were encouraged to RSI anyone that may put up any kind of fight due to the close proximity of the Pt's feet to the pilot. In this case, RSI would have been a strong option in my head.

Sounds again like you're on the right track, keep your head up, always keep asking what if and be a strong patient advocate always.

As an after thought I will throw this out there for you and anyone else who is reading this post.

What are you director's and your medical director's thoughts on RSI? Do they not like the idea of someone being paralyzed and then not being able to intubate? If that is the case, try looking up Suggamadex. It is the antidote to neuromuscular blockades. If Norcuron is used and you're unable to intubate. Suggamadex will reverse the effects and the patient will recover their own respiratory drive.

Just a thought for you to consider. You first few intubations sounded good to me accept your "Semi". Look up all the ways to confirm ETT placement. You will see that the ones that are known to fail due to inexperienced practitioners are the ones you were talking about. Visualizing the chords, Breath sounds and chest rise and fall. The can be deceiving to you in such a chaotic environment. Try relying on others as well like a good capnography waveform, no epigastric sounds, condensation on the tube, things like that.

I hope some of this helps! Take care and best of luck to you my friend you are doing well!

[nypamedic43]

It's really hard to armchair this because we didn't actually see the patient. That being said however, if she was breathing, albeit poorly, a bvm and supporting her own respirations is appropriate. Intubation is way down the list in ACLS. I'm assuming that she gad a gag reflex if you had to force the tube into place and she was biting on it. Some kind of sedation should have been given.

We dont have RSI yet and the only thing I could have given was some Valium. But something is better than nothing.

I am confused as to why your partner was concerned about knocking out her resp drive if you already had the tube. It's irrelevant at that point. You've taken the responsibility for it.

I'm interested in your follow up on this patient...especially since someone has assumed that the patient was put on a respirator, drugged into a coma and sent to the ICU to die. ( ya know what happens when you assume things). Not all patients with COPD exacerbation die.

Good post. It definitely got me thinking about what I would do in the same situation. Thank you

[systemet]

Quick points:

* I won't fault you for pulling the tube in case #2. If you have any concern that it's not tracheal, you should remove it. [Aside: capnography could have been helpful here, as could doing another direct laryngoscopy to check whether the tube has migrated, and checking insertion depth / pilot balloon inflation. But if you're still in doubt, far better that it comes out.]

* Personal opinion: in most situations missing an intubation is not critical, providing you can manage the patient with basic maneuvers. You are going to put tubes in the esophagus from time to time. As long as you recognise this promptly, and remove the tube before any harm occurs, this is minor. But letting a misplaced tube sit in the esophagus out of a refusal to accept that you may have missed is unacceptable.

* When you're not paralysing, you often have to deal with some muscle tone in the jaw. I think when you have a weak gag, a little lidospray, or a small amount of sedation can be helpful. Sometimes you can finesse the tube in. If the patient is actively biting down, and fighting the intubation, it's time to back out, give some pharmacology and approach again, hopefully with improved intubating conditions.

* You mention this may have been a primary respiratory arrest. If you're dealing with a lot of compliance issues, having to use high pressures, and having issues with oxygenation and ventilation in the post-resuscitation period, then obviously an ETT is going to be of benefit. But realise that doing an RSI is very committing. Paralysis may further compromise ventilation, and the patient will desaturate very rapidly if you're not able to adequately preoxygenate.

* If your major concern right now is airway protection, and if BVM ventilation is giving you reasonable oxygenation / ventilation, the patient's mentation is improving, and there's some spontaneous respiratory drive, it might be worth deferring the intubation. If the patient continues to improve the hospital may be able to do some magic with BiPAP.

* A lot of these patients are cardiac arrests, right? Remember that good CPR and correction of the underlying cause are the focus here.

[RaceMedic]

I have to disagree somewhat, stating up front that it is hard to tell without actually seeing the patient. This is a respiratory arrest secondary to COPD. This is not a patient who is going to get a breathing treatment and go home, she probably got sedated in the ER, put on a vent, and was sent to the ICU to die. Securing her airway via intubation is essential to properly oxygenate her lungs, forcibly expand her lungs with ventilation, and protect her airway from vomitus. Yes she will probably die anyway, but letting vomit in her lungs will definitely seal the deal.

I am really hoping by these statements that your "on the rag again" I know that it is hard to armchair this but in my experience respiratory arrest secondary to COPD is not a death sentence. I have personally bagged people out of the immediate danger enough that they could maintain on their own until i could get the CPAP set up and attached. Of these the most common out come was to spend the night in ICU then upgrade to a medical floor for diuresis and released with in a few days.

I disagee that intubation is the only choice for proper oxygenation and lung expansion. As a basic you are taught to manage airways with BVM and positioning. Yes air can and does still enter the stomach and will eventually may cause vomiting, but this is again where a basic skill should come in to play; suctioning.

By positioning i mean not only the airway but total body position. She needs to have her head up letting the fluid build up settle and taking the pressure of the intestines and other internal organs off the diaphram allowing easier and more complete lung expansion. That coupled with a foley cath (if you are able) and lasix to start shedding excess fliud.

Just my thoughts

Race

*Edit*

"* If your major concern right now is airway protection, and if BVM ventilation is giving you reasonable oxygenation / ventilation, the patient's mentation is improving, and there's some spontaneous respiratory drive, it might be worth deferring the intubation. If the patient continues to improve the hospital may be able to do some magic with BiPAP.

* A lot of these patients are cardiac arrests, right? Remember that good CPR and correction of the underlying cause are the focus here. "

I agree Systemet

Edited October 20, 2011 by RaceMedic

[hatelilpeepees]

NYPA, I did not mean that literally, that was a joke, but as far as survival; if you like, I will make a $100.00 bet with you, you follow the next several arrests over age 80 in your world, and I will in mine, until June 1st 2012. If the majority live (anything over 50%) you win, anything under 50%, I win. And by live, I mean discharged out of hospital to home, not to nursing home (that is just delayed death).

[RaceMedic]

WOW...

[nypamedic43]

You are joking right? Seriously? Give me a break. To think that I would even consider that type of thing is ludicrous. How do I know that you would be truthful....you can't even get your story straight as to why you lied about your age. You hold no credibility as far as I'm concerned.

[mobey]

^{Oh good! I get to disagree with Dwayne}

^{I dont need to comment on the sedation thing because the OP knows the Captain was wrong.}

^{An elderly female who spent (probably) all day working to breathe, using everything her intercostal, abdominal, and diaphram muscles had finally becomes so hypoxic and fatiged her body "throws in the towel" so to speak.}

^{Intubation (RSI) of this patient is absolutly indicated, those muscle groups are totally wiped out and need some recovery time, not to mention, her fragile old heart is hypoxic and has probably just worked its ass off.}

^{I say, Intubate, paralyze, cool, correct the acidosis, and let this patients cardiorespiratory system recover before waking her up again.}

^{We are not talking about a COPD exacurbation anymore, we are talking about post-cardiac arrest care with respiratory failure.}

^{http://circ.ahajournals.org/content/108/1/118.full}