Quote from Toby's mum
Within 30 minutes of entering the ICU, she underwent an awake intubation. Although she received approx 8 mg Versed and 2 mg morphine (I think?), there was no succinylcholine on the ICU floor, which is what the CRNA requested. Since the patient was rapidly desating and going into bradycardia, the CRNA made a decision to do an awake intubation. The patient was not paralyzed at this point. After intubation, the respiratory therapist assisted with respiration. Shortly after this time, the patient's belly significantly expanded outward and, while being suctioned, significant amounts of a pink, frothy substance was expressed. It even looked like there may have been tissue mixed in. The patient then coded twice.
My questions related to this experience are as follows:
1) is it typical to keep succ on the ICU floor for emergency intubation or do you use something else--perhaps Nimbex (sp?)
2) What is the significance of the belly expanding shortly after intubation and manual bagging? The CRNA was pretty confident that the tube was placed correctly since he didn't hear any gurgling in the LUQ.
3) How can you tell the difference between aspiration (that may have severely damaged the lungs) and pulmonary edema that was suctioned out in a profuse amount.
1) Interesting how different practices do things differently. During a near-code, it is often not necessary to use any muscle relaxants for intubation. A full code doesn't require any. However, I will respectfully disagree with Tenesma that Sux is contraindicated in these cases. We treat most of our urgent intubations in the ICU just like a rapid sequence induction - pre-oxygenate as much as possible, and either some versed, low-dose propofol, or perhaps etomidate, and then Sux more often than not. Many intubations can be done without a muscle relaxant, but that doesn't mean that using them is poor practice.
2) If things happened as you described it, I would say this is a case of dangerous incompetence. If they didn't check breath sounds and use some sort of EtCO2 device to confirm tube placement, they have committed malpractice, plain and simple. This is a standard of care - "pretty confident" isn't even close to being good enough. I think the end result for this patient pretty much speaks for itself.
3) Although not absolute, fluid from pulmonary edema is often described as "pink frothy", while gastric contents often have that lovely yellow tinge from bile. However, you could easily have a mixture, so I wouldn't depend on this. Peas and carrots in the lungs are a good tip-off however.
In the case you quoted, 8 of versed and 2 of MS is just about a general anesthetic for this patient, so I wouldn't truly call this an awake intubation.
One other comment regarding blade choice - the debate will forever rage about straight vs curved blades. Tenesma likes his straight blades, I wouldn't attempt an intubation without my Mac. Half of my group uses straight blades (the "professional" blade to them). Half of us use curved blades (anyone can muscle a tube in with a straight blade - it takes skill and finesse to do it with a curved blade
) The important points are 1) know how to use both blades and 2) get really, really good with one of them, and use it all the time.