Intubation necessary?

Esme12, ASN, BSN, RN · Dec 26, 2014

I think you need to have some faith in the healthcare system. The treatment of a patient in the emergency department with such an acute presentation is different than the ICU patient admitted to the hospital.

I would be cautious of anecdotal articles talking abut what should or should not be done for it is impossible to apply to the actual patient in a crisis presenting to the ED. Of course they are not familiar with her case....they had never seen her before.

This is from medscape...it is free but you must register.....Medscape: Medscape Access

Esme12, ASN, BSN, RN · Dec 26, 2014

Hi TrauamNurse,
Thanks for the reply. I can understand that...I guess my confusion arouse from the fact that the ICU team wanted to do the MRI/MRA the next day without intubating her but the ER doctor said he was worried about the AFE so he wanted to do the intubation and the MRI/MRA right away. I guess in retrospect I should have denied the MRI/MRA until the morning and she probably would have never been intubated and probably could have recovered quicker. All sources and case studies have said that intubation should be a last resort for postpartum eclampsia unless they go into SE, but perhaps they weren't familiar with the situation (they kept saying they were unsure of her case). Luckily she never experienced the HELLP or DIC!

I think you should also consider that the ER doc is looking at all variables. She very well could have had an AFE or a bleed/aneurysm that might of required immediate intervention and waiting could have endangered her life. The intubation was to sedate her enough so they could obtain testing to further diagnose or narrow down differentials. By the next day she was "stabilized" within reason AND it was morning with plenty of day shift employees meandering about to help.

The intubation was to sedate her enough to get the testing accomplished which is usual and customary in the emergency department and had probably nothing to do with the eclampsia per se. Emergency is a different animal all together.

Waiting might not have had her recovering quicker if she had a leaking aneurysm from the HTN and eclampsia.

MunoRN, RN · Dec 26, 2014

I can't really speak the specific situation since I wasn't there, but in general it is sometimes necessary to sedate a patient for an MRI, often the level of sedation required necessitates intubation for safety. I've found this to be particularly true of patients who are getting an MRI related to seizures since I can't actually remember ever putting a patient with recent seizures into an MRI where they didn't end up having more seizures due to the MRI machine. If you tried to invent a machine to induce seizures, the only way you could improve on the design of an MRI would be to add a strobe light.

Ideally patient's are intubated for the shortest duration possible, but there are sometimes good reasons to avoid the urge to extubate too quickly, and this might be one of those situations. Propofol has a powerful anti-seizure action, stopping the propofol to extubate could "un-mask' an impending seizure, which could be very bad combined with the airway inflammation/irritability that can result from being intubated. If a patient is going to have a seizure after extubation combined with a difficult re-intubation then they might be correct that it is worthwhile to wait until someone other than a nervous resident is immediately available.

As far as the experience with being intubated, what you describe is pretty typical, it's rarely a pleasant experience for anyone, particularly friends/family of the patient unfortunately.

ScottieDNurse2b · Dec 27, 2014

I'm sorry, I think I must clarify. Besides her blood pressure, the rest of her vitals were normal...she was not unstable when she was brought in (although combative, but they restrained, sedated, unrestrained). She never had a seizure at the hospital. Hell, even her bloodwork looked good. She had a CT and MRI performed at first. The CT came back with PRES, no aneurysm/bleed/stroke or anything like that. The MRI did not produce a clear picture, although they did obtain one (sedate more perhaps?). The OB said it was eclampsia/PRES/she'll be fine, nothing to worry about, she'll be out of here by Tuesday (ended up being Thursday after all this). The ER doctor wanted to intubate to get a clearer picture. The OB and ICU team wanted to wait until the morning. I can understand the ER doctors concern, but she was intubated SIX HOURS after she arrived at the ER. If she was intubated upon arrival and was crashing, I can understand his concern. I even can understand the desire to intubate her to run the tests...and I was fine was this. That's why it was done. The MRI showed nothing that the CT didn't show. But it's not a good reason to say she needed to be intubated overnight "in case she has another seizure" when she was never intubated for six hours after arriving in the ER after having her seizures.

However, had I known she was going to be left intubated over night, I would have waited until the morning. The residents, ICU nurse, and ER doctor were all for extubation after testing was done. The overriding vote was the attending ICU doctor who was at home, who then proceeded to come into her room the next morning and told me the wrong reason she was intubated (quote, "I heard we had to intubate her because she had trouble breathing.") After I explained the "real reason," she was extubated quickly without incident. I'm sorry, but this seems "fishy" to me...the doctor doesn't know why she's on the vent? If it a case of lack of staffing or professionals at night, then that's crappy she had to suffer with unncessary intervention for 15 hours because they don't have enough staff. Hell, they are a trauma center!

These are not anecdotal stories, these are standards of care for women with eclampsia: "intubation should be the last resort." Even women who had seizures at the hospital were never kept intubated unless they had SE. I understand the desire for testing, but get that thing out of there when you're done. I do have faith in the healthcare system, but it's unnerving to know that medical errors are the third leading cause of death in the U.S. So basically she was given a harsh sedative and had a machine breathe for her of which her body could have done all on its own. She had infiltrate in her lung when she was intubated, xray day after extubation showed it gone. Too much intervention and care is not necessarily a good thing! I'm just happy that she wasn't adversely affected by the intubation except for having to wear oxygen for three days after.

MunoRN, thanks for the reply. I was reading up on Propofol and although there seems to be some evidence of its antiseizure activity, there is much controversy surrounding it. Some sources say that it actually can cause convulsant behavior (called seizure-like phenomena). It seems Propofol is good at controlling SE, but she never had that. She never had any seizures at the hospital. Luckily she never had any bad side effects or "awareness" while on it! As for it not being a pleasant experience, it definitely was not! I had to stop her from pulling it out because they didn't have her restraints tightened, probably because I was there all night (although they say if they are a ready to pull it out that means they should have it out!).

I will try to get some answers and hopefully I will be able to report back to let you know what they said! :-)

ScottieDNurse2b · Dec 27, 2014

Oh, and MunoRN, she did have the EEG done with the strobe light on Monday (seizures happened Saturday at noon). She doesn't remember the light at all, but she does remember that sticky glue in her hair! LOL

Altra, BSN, RN · Dec 27, 2014

I'm glad to hear of the good health of your fiancée and your son. Enjoy the beauty of your new family during this holiday season.

Loo17 · Dec 27, 2014

I'm sorry, I think I must clarify. Besides her blood pressure, the rest of her vitals were normal...she was not unstable when she was brought in (although combative, but they restrained, sedated, unrestrained). She never had a seizure at the hospital. Hell, even her bloodwork looked good. She had a CT and MRI performed at first. The CT came back with PRES, no aneurysm/bleed/stroke or anything like that. The MRI did not produce a clear picture, although they did obtain one (sedate more perhaps?). The OB said it was eclampsia/PRES/she'll be fine, nothing to worry about, she'll be out of here by Tuesday (ended up being Thursday after all this). The ER doctor wanted to intubate to get a clearer picture. The OB and ICU team wanted to wait until the morning. I can understand the ER doctors concern, but she was intubated SIX HOURS after she arrived at the ER. If she was intubated upon arrival and was crashing, I can understand his concern. I even can understand the desire to intubate her to run the tests...and I was fine was this. That's why it was done. The MRI showed nothing that the CT didn't show. But it's not a good reason to say she needed to be intubated overnight "in case she has another seizure" when she was never intubated for six hours after arriving in the ER after having her seizures.
However, had I known she was going to be left intubated over night, I would have waited until the morning. The residents, ICU nurse, and ER doctor were all for extubation after testing was done. The overriding vote was the attending ICU doctor who was at home, who then proceeded to come into her room the next morning and told me the wrong reason she was intubated (quote, "I heard we had to intubate her because she had trouble breathing.") After I explained the "real reason," she was extubated quickly without incident. I'm sorry, but this seems "fishy" to me...the doctor doesn't know why she's on the vent? If it a case of lack of staffing or professionals at night, then that's crappy she had to suffer with unncessary intervention for 15 hours because they don't have enough staff. Hell, they are a trauma center!
These are not anecdotal stories, these are standards of care for women with eclampsia: "intubation should be the last resort." Even women who had seizures at the hospital were never kept intubated unless they had SE. I understand the desire for testing, but get that thing out of there when you're done. I do have faith in the healthcare system, but it's unnerving to know that medical errors are the third leading cause of death in the U.S. So basically she was given a harsh sedative and had a machine breathe for her of which her body could have done all on its own. She had infiltrate in her lung when she was intubated, xray day after extubation showed it gone. Too much intervention and care is not necessarily a good thing! I'm just happy that she wasn't adversely affected by the intubation except for having to wear oxygen for three days after.
MunoRN, thanks for the reply. I was reading up on Propofol and although there seems to be some evidence of its antiseizure activity, there is much controversy surrounding it. Some sources say that it actually can cause convulsant behavior (called seizure-like phenomena). It seems Propofol is good at controlling SE, but she never had that. She never had any seizures at the hospital. Luckily she never had any bad side effects or "awareness" while on it! As for it not being a pleasant experience, it definitely was not! I had to stop her from pulling it out because they didn't have her restraints tightened, probably because I was there all night (although they say if they are a ready to pull it out that means they should have it out!).
I will try to get some answers and hopefully I will be able to report back to let you know what they said! :-)

ER docs tend to think worst case scenario and want to cover all their bases. They have seen things go south and quickly.

It is easy for you or anyone to say after the fact that you should have waited because you know what the outcome turned out to be. The ER doc was advocating for your loved one and making sure to be prepared for the worst case scenario. What I think is unfortunate is that the different disciplines/departments that were present disagreed about the course of treatment in front of you. I dont find her OB's opinion to be relevant at all since they were not there. I think the fact that one person told you one thing and the other told you something else without it fully being explained to you why they decided one thing is what placed doubt in your mind.

Things could have went differently sure. You could have refused intubation and had the MRI the next morning and got discharged 2 days earlier or you could have refused intubation and your loved one could have seized again, aspirated, threw a clot, burst an aneurism, had a difficult emergent intubation and been hospitalized for weeks or even worse, died.

A person being stable is more than just vitals. You said it yourself she was a healthy 24 year old. Stable 24 year olds typically do not have seizures after giving birth, their blood pressure is not usually high, they don't have horrible headaches, or get so confused they need to be restrained. Your loved one was not a stable postpartum mother regardless if her pulse was normal, she was afebrile, and could breathe normally. The ED doc did everything they believed possible to make sure she could get home to you and her baby. They did not take any chances. They did not say it can probably wait until the morning, cross their fingers and hope for the best. I hope you are able to get closure and move on from this feeling like you did everything you could to keep your family whole. Congrats on the baby!

Trauma Columnist · Dec 27, 2014

We are glad you all are doing well now. You have received some excellent advice. Perhaps discussing this all with the provider will bring you some closure. Take care.