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[This has been floating about as a draft post here for ages, but Cliff has finally inspired me to put it out there and have the discussion following his recent post on The tongue-in-cheek non-intubation check list]
This is one of the trickiest decisions in EM in my opinion. Now for lots of patients it’s really easy: the severe sepsis with white out pneumonia or the severe head injury.
However, lots of people fall somewhere in between. In the past 6 months I’ve treated a number of patients where the decision could have gone either way. For example, here’s some theoretical cases. I’ll let you work out the (hopefully) obvious diagnoses.
Case 1
72 male presents via ambulance at 0500 having woken from sleep with shortness of breath.
He is clearly unwell with a systolic BP of 180, HR of 180 a horribly broad LBBB ECG with a rate of 110. He is diaphoretic, agitated but responsive to voice with sats of 70 on oxygen. His RR is 30 and the chest is wet like an Irish summer. GCS is single figures.
pH 7.0 pCO2 8 pO2 6 on arrival (they’re in kPa if you’re wondering)
Do they get the blue cigar?
Case 2
A young male presents via ambulance after being found agitated and delirious trying to catch a bus.
He is massively diaphoretic, agitated, tachy at 170 with a normal QRS but a dominant R in aVR. He is moderately hypertensive at 150 systolic. He tells you he wants to leave so he can catch his bus.
His lactate is 20 and he is producing dark coloured urine and has a CK greater than 100000.
Do they get the blue cigar?
Case 3
A middle aged male, with a preponderance to drink strong beverage and a tendency to have seizures, is found on the floor of a hostel seizing with a wound and grossly swollen right peri-orbital area. He has two further seizures on route to hospital and one in the department. It is now 30 mins from the first seizure and he has not returned to baseline.
Do they get the blue cigar?
Let me know in the google form and give some reasons in the comments. You’ll all want more information but you’re not getting any. I’ll give some follow up next week.
Thanks for the mention Andy!
Quick thoughts:
1. No. At least not yet. This is what Weingart would call SCAPE. May well improve with NIV and GTN ivi. For sure might require ETT eventually but the physiology and logistics of doing it as first line in this chap versus a (safe) trial of the alternative would lead me to try the latter first.
2. Yes. Probably. Looks like he has rhabdo. Tube needed for treatment of the pathology (surley will need CRRT on ICU amongst other things) but also perhaps will be needed to restrain him. I presume he will not hae capacity and IM sedation is likely of limited use here.
3. This one is a no brainer in my book. He’s bordering on a status presentation. Possible bleed. Needs ETT for safe CT and whatever comes next. If CT normal and he wakes up, you can always remove it.
Or have I missed something?
cheers for getting the ball rolling. Good reasoning for all three. I’ll leave my thoughts for the follow up.
Hey Andy
The decision to take over the airway and pilot it yourself carries a lot of implications. Case1 the70 yo man with pulmonary oedema and low GCS in single fingers (LOL) deserves a trial of NIPPV despite the conscious state. Hypoxia is his issue and it may well dramatically improve with mask CPAP for example. Its worth a shot and you can tell if it is going to work within 10-20 min
Case 2 is a sick young man with serotonin syndrome, stimulant toxicity or been bitten by a nasty Australian venomous snake with myotoxicity. He is pretty sick and his expected clinical course is to deteriorate and maybe die. He needs possible renal replacement Rx and something to control his hypertension and delirium like propofol. So he gets the blue cigar as entry ticket to an ICU
Case 3 is status epilepticus with head injury. Medical Rx with phenytoin is not going to cut it. He needs a GA and CT and maybe retrieval if neurosurgical lesion found.
Nice ones Andy and thanks for the ‘smoking the blue cigar’ pingbacks. gonna get Jamie Doube on the ruraldoctors.net podct soon after his experiences down on Sth Georgia with ‘Team Rat’
Ok, my thoughts
1/ no, intubating LVF is last ditch. He needs a decent trial of NIPPV. Similar case over in the crit care forum on doctors.net.uk this week from point of view of ICU outreach, more about intubating on wards vs ICU vs OT with inexperienced assistants…
Gonna jump to
3/ yep, borderline uncontrolled status…needs CT head. I’d intubate for CT transfer and neuroprotection
Then back to (2) ‘it depends’
2/ it depends. Not so keen on ICU = tube. Yes he’s got rhabdo from his excited delirium toxidrome….but he needs rapid takedown and aggressive Rx for his bung kidneys.
I’m going to chuck this one back at Minh – if he was from an isolated community, weighed 140kg, unfasted, no neck and you were an ‘occasional intubator’, would you want to intubate him? Or take down, sedate and treat on ICU with 1:1 with preserved airway reflexes…
I am trailing a coat here….Minh?
The over-arching consideration here should be ‘will this patient’s management be improved if he is intubated and ventilated?’
In none of the cases will intubation be the definitive management of the patient’s problems, and it should be considered an adjunct to definitive treatment.
The concept of an ‘Entry Ticket to ICU’ (‘m sure tongue-in-cheek in this case) is unfortunately occasionally seen, where a patient is intubated, but then languishes awaiting further definitive treatment in the ED.
It should be less of ‘Tube’s in, he’s now awaiting ICU’ and more ‘Tube’s in, now let’s get to work…’
For the record:
(1) Nup. NIV and cardiac treatment first go here.
(2) Yep. Needs complex care, no place for non-compliance there, likely to get sicker before better.
(3) Probably yes. Unless he wakes up quickly, he needs his head scanned. Needs to be done safely and effectively. Scan ok and waking up? Pull the tube afterwards…
Exactly! Intubation is rarely if ever definitive management.
The ‘entry ticket to ICU’ was indeed tongue in cheek. I was more referring to the situation where a patient may well benefit from ICU care but does not go there due to the ‘non-clinical factors’ like no beds. I’d love to say we have endless resources but we just don’t. However an intubated patient (who has hopefully been fully treated like you say) mandates an ICU bed.
I’ll post some more on the follow up blog in a few days.
Can’t agree that “an intubated patient mandates an ICU bed”.
A requirement for critical care mandates an ICU bed, not absence or presence of a piece of plastic.
The last patient I saw that was intubated in the ED certainly didn’t get admitted to ICU- they were extubated, sent to a medical ward, and then home the following day
Also, ICU certainly doesn’t have “endless resources” either – I wish we did!!
Front the above cases:
1. No, and would be a particularly bad choice first line
2. Maybe. Definitely yes if lacking capacity and failing to cooperate with treatment. Would benefit from short period of resuscitation prior to intubation if possible.
3. Yes. Needs intubated.
-John
I meant someone with an ET Tube with ongoing critical care requirments (as you say) will mandate an ICU bed.
What defines “critical care requirements” is a fairly subjective, or at least complex, call. I don’t mean that as a bad thing – this is the art and skill of the intensivist. Whereas the need for ongoing intubation is a fairly black and white “critical care requirement”
I totally agree with extubating the patient in whom it’s not appropriate. We’re happy stopping CPR when we realise it’s futile so why not the tube.
When I said “endless resources” I was specifically thinking of ICU.
OMG, John Hinds and I agree!
1/ no
2/ maybe
3/ yep
Me too! My rationale for pt one is a trial of BiPAP – systolic BP good enough to tolerate IV nitrates and whatever else is indicated (?beta blockade). You’ll need some background on him too – he isn’t all that young and past medical history comes into play here. Worth a quick chat to family to see what his thoughts about this situation might have been and then if BiPAP fails you’re in a better position to decide to intubate (or not). Maybe I’m biased by our local population but we see a lot in their 70s and 80s who already have complex health and clear ideas about the care they do and don’t want. So my answer was “not yet”…
I’m with you on three – CT needed which will be nearly impossible and certainly unsafe without induction & intubation.
Got a temp on patient two? If there’s a chance of hyperpyrexia as part of his apparent toxidrome then that reinforces my yes vote but given that he is attempting to leave (in our dept often on the grounds that he is “well sound”) without capacity AND needs a reasonable volume of fluid to keep those kidneys going I think sedation +/- intubation is probably needed. He’s one I’d probably work with my colleagues to make a decision for – if the intensivists aren’t keen to intubate I’d accept sedation as long as it had the desired effect but with a proviso to review and reconsider if he remains a challenge to manage.
In summary:
1 – not yet
2 – most likely, yes
3 – yup
Nat
Case 1 needs a trial of NIV as part of his after load reduction therapy first, but I suspect will end up with a tube. Case 2 won’t hold still for his dialysis without a tube and as for case 3, while he’s probably just PFOed, I think given the evidence of trauma he a tube for his scan. My 2c. D
1. Not yet. CPAP and standard therapies first. Should buy some time and stability if you need to tube down the line.
2. Yes.
3. Yes.
Yes for reasons mostly explained far more eloquently above.
Team,
I’m going to be oppositional. If anything it ought to make things more interesting.
[1] Intubate. This man has a several contraindications to noninvasive ventilation, specifically agitation, likely myocardial ischemia, and quite severe acidosis. I agree that acute cardiogenic pulmonary edema can often be salvaged with noninvasive ventilation, but the combination of severe hypoxemia, hypercapnia, and agitation makes this unlikely to suceed. Furthermore, it sounds like he may be in the throes of an acute anterior wall MI in which case he would require urgent cardiac catheterization (which would require intubation prior to the procedure).
[2] Do not intubate. This gentleman sounds to have a sympathomimetic (or similar) intoxication with rhabdomyolysis but is protecting his airway and in no imminent physiologic danger. He could benefit from sedation as well as vigorous IV fluid resuscitation. There is no indication for urgent dialysis at this point. His lactate is high, but I suspect once he calms down and stops chasing busses it will normalize promptly. He is young and could very well do just fine with conservative management (sedation & hydration).
[3] Intubate to facilitate CT scan. If he has no CNS bleed and starts waking up he could potentially be extubated shortly. He’d probably do just fine with medical management of his seizures, but I think the standard of care is to intubate and scan. He’s not stable enough to leave the department without a secured airway.
Josh
1st case – rather yes, pt in extremis on his way to cathlab, if no improvemnt after short course of treatmnt definite airway – low GCS, low O2… Needs sedation or GA, oxygen supply to meet metabolic demands of ischaemic myocardium and brain.
2nd case – OETT not yet… Depends on the further course of action and of course on the diagnosis. If he does not present respiratory insuffitiency the tube will not help him, but renal protection and fluids will.
3rd pt gcs <9 I'd intubate on scene. If low GCS, trauma, alcohol, seizures – lower CMR02 and put the tube and to CTsuite.
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