Intubation and the unconscious

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Medic305

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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!
 
Nothing wrong with just taking a look to see if she tolerates the DL/VL without anything. You can always come out and give her something. You can hedge your bet in this by giving a 2\kg bolus of lidocaine, waiting 2 minutes and then take a look. By the sound of it, that very well could be all this lady needed....but....

You should absolutely hand ventilate yourself (not take someone else's word for it) to be sure that there is chest rise, lung compliance, etc. to get some idea of just how unconscious she really is. IME, someone that accepts positive pressure ventilation as if they were completely flaccid probably won't need much hypnotic/sedation or even paralysis for DL/VL intubation. She'd probably dump her BP with even a modest dose of etomidate FWIW
 
E tank said:
Nothing wrong with just taking a look to see if she tolerates the DL/VL without anything. You can always come out and give her something. You can hedge your bet in this by giving a 2\kg bolus of lidocaine, waiting 2 minutes and then take a look. By the sound of it, that very well could be all this lady needed....but....

You should absolutely hand ventilate yourself (not take someone else's word for it) to be sure that there is chest rise, lung compliance, etc. to get some idea of just how unconscious she really is. IME, someone that accepts positive pressure ventilation as if they were completely flaccid probably won't need much hypnotic/sedation or even paralysis for DL/VL intubation. She'd probably dump her BP with even a modest dose of etomidate FWIW
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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.
 
Medic305 said:
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.
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If you were hesitant about using induction agents initially you should continue that thought. 5mg and 100mcg have a high likelihood of hemodynamic instability (especially with no stimulation of DL and endotracheal intubation following) in a patient like this. That patient's BP is likely only holding from high sympathetic outflow.
 
Medic305 said:
This isn't a real patient, just a scenario that I played out in my head
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Oh yes it is...there are a million like her...
Medic305 said:
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.
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An obtunded, frail patient like that would probably not need much of anything, much less 5 mg of versed. I'd give her that much for an entire open heart anesthetic and she'd be a lot healthier for that. Maybe 2 of versed and 50 maybe 100 of fentanyl...more than that and you might be sorry.
 
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That’s a Pennsylvania SAI. Etomidate or Ketamine, no paralytics.

We do them often.
 
MonkeyArrow said:
Right, but then OP mentions pushing etomidate...
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I thought he meant he did not have that option so was not sure he could intubate a patient without meds.
 
E tank said:
Oh yes it is...there are a million like her...

An obtunded, frail patient like that would probably not need much of anything, much less 5 mg of versed. I'd give her that much for an entire open heart anesthetic and she'd be a lot healthier for that. Maybe 2 of versed and 50 maybe 100 of fentanyl...more than that and you might be sorry.
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I agree with you 100% I'm not a "follow your protocol" medic, I use them as guidelines. I would under dose in this scenario.
 
Medic305 said:
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!
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First you need to try to manage her shock index. A heart rate of 140 with an SBP of 100 is a shock index of 1.4 and it is highly likely she will rapidly decompensate with sedation and/or vagal stimulation from the intubation attempt.

My vote on this case is an NPA, better bvm technique, aggressive fluid resuscitation, and rapid transport.

ETA - her SpO2 is also far to the left of the oxygen curve, giving further reason to aggressively resuscitate this patient first. In her current state, RSI/MAI has a high chance of killing her.
 
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FiremanMike said:
First you need to try to manage her shock index. A heart rate of 140 with an SBP of 100 is a shock index of 1.4 and it is highly likely she will rapidly decompensate with sedation and/or vagal stimulation from the intubation attempt.

My vote on this case is an NPA, better bvm technique, aggressive fluid resuscitation, and rapid transport.

ETA - her SpO2 is also far to the left of the oxygen curve, giving further reason to aggressively resuscitate this patient first. In her current state, RSI/MAI has a high chance of killing her.
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Getting into the weeds here given the setting and context, but shock index as a predictor of mortality across populations may not be so reliable...to wit: a shock index of 1.4 in a 78 year old woman is not the same shock index of 1.4 in a 24 year old with a lacerated liver. That and it doesn't have to be an 'either/or' type response. A volume bolus with/before DL would be prudent tho, agreed....
 
E tank said:
Getting into the weeds here given the setting and context, but shock index as a predictor of mortality across populations may not be so reliable...to wit: a shock index of 1.4 in a 78 year old woman is not the same shock index of 1.4 in a 24 year old with a lacerated liver. That and it doesn't have to be an 'either/or' type response. A volume bolus with/before DL would be prudent tho, agreed....
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Fair enough, good point
 
Lucky we have Versed and Fentanyl.
I would give her a little of both; intubate, and drive slow (Ambulances do 75 and speed limit is 80) to meet a bird and fly them to a hospital. Closest hospital that will take this type of patient is 135 miles, and a bird would take 35-50 minutes on average.

I have done 3 patients like this, this year. Only 1 could I get a tube into early on; 2nd one, just as the bird landed.

What really sucks is when they can't fly. Like a few years ago for a 5.5 hour transport for an Active STEMI during a blizzard. 12 hour round trips suck.
 
Medic305 said:
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!
Click to expand...
Not sure how your protocols are setup but if your patient is unconscious and no gag reflex, there’s no reason to give etomidate.
 
I saw you mentioned this was just a hypothetical patient, but nonetheless with that pressure, lung sounds, and tachycardia, it definitely paints a realistic picture of a septic pneumonia patient, one that you'll almost certainly run into at some point in your career. I'm not a huge fan of SAI/MAI to begin with, but if this was your patient, I'd be very hesitant to use anything more than 2mg versed and/or 50mcg Fentanyl to facilitate intubation. 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.
 
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