social intubation?

LMPhilbric · Jun 11, 2008

I have heard a doc threaten a pt with it, but have never actually seen the follow through. Now we've had people who've had to be sedated to the point where they needed to be tubed to protect their airways. That's a different animal. I would never tube anyone for kicks, and wouldn't let a doc do it either, but let's be real. When someone is going to be assaulted in the ER, it's not going to be me. I will take whatever measures are necessary to protect me and the other members of my team. Part of my job description is not "will willingly allow self to be assaulted by drunk/high/crazy people." If I get hurt and can't work again, then my family doesn't eat/have a roof over their heads/go to school etc. It's not worth it. If it means someone needs to be tubed and sedated to protect the medical/nursing staff, so be it. On an interesting side note, I had a DTer the other day who was so bad, it took 22 mg of Ativan and 5 mg of Haldol to bring him down so I could start the Ativan drip. I didn't have to tube him either. He was fine on a NRB. That would have killed me at least 10 times over.

TraumaNurseRN · Jun 11, 2008

i have heard a doc threaten a pt with it, but have never actually seen the follow through. now we've had people who've had to be sedated to the point where they needed to be tubed to protect their airways. that's a different animal. i would never tube anyone for kicks, and wouldn't let a doc do it either, but let's be real. when someone is going to be assaulted in the er, it's not going to be me. i will take whatever measures are necessary to protect me and the other members of my team. part of my job description is not "will willingly allow self to be assaulted by drunk/high/crazy people." if i get hurt and can't work again, then my family doesn't eat/have a roof over their heads/go to school etc. it's not worth it. if it means someone needs to be tubed and sedated to protect the medical/nursing staff, so be it. on an interesting side note, i had a dter the other day who was so bad, it took 22 mg of ativan and 5 mg of haldol to bring him down so i could start the ativan drip. i didn't have to tube him either. he was fine on a nrb. that would have killed me at least 10 times over.

for kicks???? nah! when we have an out of control patient, whether it be tbi or trauma/drunk....we tube them to protect them. i do not think any ed does this for kicks....22mg of ativan though..... is a worry, and they could have been safely intubated/sedated and enabled to detox safely. wow on the ativan!!!! ( besides the documentation on that conscious sedation method.....)

Altra, BSN, RN · Jun 11, 2008

It is *sobering* when you give doses of meds to your patients that you know would probably kill you.

I've given 18mg of Ativan over a few hours. After the first 8mg, I was thinking to myself, "I'd be dead by now."

LMPhilbric · Jun 11, 2008

For kicks???? Nah! When we have an out of control patient, whether it be TBI or trauma/drunk....we tube them to protect them. I do not think any ED does this for KICKS....22mg of ativan though..... is a worry, and they could have been safely intubated/sedated and enabled to detox safely. Wow on the ativan!!!! ( Besides the documentation on that conscious sedation method.....)

Actually, that is our protocol for alcohol withdrawal, and it's not considered conscious sedation. Based on the CIWA scale, you give 2-8 mg of Ativan to start. If they are over 25, you give 4, then 4 10 mins later. If that doesn't work, you give 8 until you achieve sedation. If they are actively hallucinating or if it takes more than 8, you can add the Haldol. When they are hardcore alcoholics, they can take staggering doses of Ativan with little effect. It replaces the alcohol and keeps them from seizing. We can actually go up to 40 mg on the Ativan. Then you base the continuous on how much it took to get them down in the first place.

LMPhilbric · Jun 11, 2008

I guess I should have specified...over 25 means, over 25 on the CIWA scale. 1-8 is mild withdrawal, 9-24 is moderate and over 25 is severe and an automatic critical care bed.

TraumaNurseRN · Jun 12, 2008

Actually, that is our protocol for alcohol withdrawal, and it's not considered conscious sedation. Based on the CIWA scale, you give 2-8 mg of Ativan to start. If they are over 25, you give 4, then 4 10 mins later. If that doesn't work, you give 8 until you achieve sedation. If they are actively hallucinating or if it takes more than 8, you can add the Haldol. When they are hardcore alcoholics, they can take staggering doses of Ativan with little effect. It replaces the alcohol and keeps them from seizing. We can actually go up to 40 mg on the Ativan. Then you base the continuous on how much it took to get them down in the first place.

I stand corrected.....but wow......I wouldn't be standing for long...lol

LMPhilbric · Jun 12, 2008

That's because you're not a hard-core alcoholic. The first 2 would have me put down from now until Christmas. If you could have seen this guy, he was just wild. They found him up a tree. He was hallucinating and wild. It was really sad. I gave him 2, no response, 4, no response, 8 no response, 5 of Haldol, no response, another 8 mg and he finally settled down. Mind you, when they came in to do his portable chest, he woke back up (that's on a 6 mg/hr drip!). It's better than having them seize. I hate it when that happens.

MassED, BSN, RN · Jul 15, 2008

Note : I am not a nurse, but a medic but have worked in level one trauma center in that capacity
I was reading a post in another site and it brought up a valid question in my mind from when I worked in ER. I saw many patients intubated (RSI) for the convenience of the physician and staff if they were obnoxious. This included drunks and just downright difficult people sometimes with relatively minor problems. More than once I heard the comment "settle down or I'll put you down !" and it was done. What is your experiences with this and how do you feel about it? Do you ever question the docs when they do this or is it appreciated? I'll be the first to admit, yes, it did make them easier to manage, but tied up space in the ER longer and usually made them end up being admitted overnight for observation. I'm just curious if anyone else questioned that judgement call. Doing ground CCT transport in a rural area now, it's used alot for transports due to 2 hours plus sometimes to trauma center with no ability to fly 'em and I'm not going to manage a difficult patient for 2 hours by myself, but just for convenience in the ER? I'm not seeing much of a need for this and wondered if it was prevelant in other areas or just in that particular ER. Thanks !

yep - worked with a few docs who would do this on some occasions, depending on the extent of illness, if they were compliant with treatment (drunk and belligerent, for instance).... and if they were in danger of getting up, moving, hurting themselves further... it's not right, but when there are other serious things going on it's easier to care for a patient on a vent.

MassED, BSN, RN · Jul 15, 2008

These meth stories kinda fascinate me ... meth is rare in my neck of the woods. Drugs of choice in my hospital's hood are the old standbys - heroin & crack.

meth hides everywhere... you may think it's not around, but you never know..... quite scary, actually. In N.C. there was a huge drug bust in this small little town near where I lived - no one ever suspected what was going on in a residential neighborhood. When I lived in Washington state, we were constantly in-serviced on meth abuse in that region, as it was so prevalent.