Intubation and Sedation

mwboswell · Apr 7, 2011

Msn10, we are not talking about what is on an anaesthesia cart in the operating theatre. The OP is discussing a case specific to the emergency room. Thiopental is not an agent that you will likely encounter in a typical emergency room. Also, "modified RSI" versus "RSI" is frankly an argument in semantics regarding the OP's questions.

I agree with GilaRN...

While I appreciate Msn10's extensive knowledge base and ability to convey some good educational points - I wouldn't want the mainstream ED folks to get overwhelmed with some of those concepts. I imagine the ED folks reading this have NEVER (in the ED setting) seen, touched or maybe even have heard of curare or thiopentathol...!?

But not to put Msn10 down or anything - I just would hate to see some new folks get overwhelmed and confused.

Likewise in my "other" career (EMS paramedic on the side) our state mandated "RSI" classes have never gone to such depth, and we do it a whole lot more often than some of the ED MD's....

But thanks for the good topic!

-MB

qcumba · Apr 10, 2011

Reading through all these replies, it seems that we are the only unit who uses Midazolam/Dormicum, for intubations,and then dormicum and morphine post intubation for sedation, is there anyone else who does this?

allnurses Guide · Apr 10, 2011

Reading through all these replies, it seems that we are the only unit who uses Midazolam/Dormicum, for intubations,and then dormicum and morphine post intubation for sedation, is there anyone else who does this?

If that is all your unit uses for intubation then your patients are at a high risk for an MI or CVA from the unblunted sympathetic surge caused by the DL.

GilaRRT · Apr 10, 2011

If that is all your unit uses for intubation then your patients are at a high risk for an MI or CVA from the unblunted sympathetic surge caused by the DL.

References?

allnurses Guide · Apr 10, 2011

References?

No references needed unless you are using high dose versed then the sympathetic discharge from the DL is enough to cause severe tachycardia and HTN. Anyone that has any underlying CAD/vascular problems is going to be put at severe risk for CVA and/or MI. This is intubating 101.

http://vdmtc.org/module03/intubate/intubate03.htm

GilaRRT · Apr 10, 2011

I'm not seeing how this special case can be generalised to all patients being at "high" risk.

allnurses Guide · Apr 10, 2011

I'm not seeing how this special case can be generalised to all patients being at "high" risk.

Am I missing something or are you intubating patients that are a lot healthier than the average person that has to be intubated (or am I just tired from finishing a 24hr shift and missed something on this thread)?

Every patient that is going to be intubated outside the OR for nonroutine purposes are high risk patients.

Are you saying it doesn't matter if a patient only gets Versed during their intubation and their BP goes sky high and ICP dramatically increases? There are literally thousands of patients that have had MIs during intubation. Patients have MIs everyday during intubations, so I am missing what your point is.

Also, I am not referring to intubating a totally obtunded patient that doesn't need anything because of severe trauma or has coded and is in complete arrest.

GilaRRT · Apr 10, 2011

Im just not aware of compelling data that says patients intubated with midazolam are consistently at high risk for MI and so on from catecholamine dump versus other agents. Much of the data I've seen actually tells a different story regarding myocardial depression and haemodynamic changes such as hypotension. We are talking about induction doses of midazolam yes?

allnurses Guide · Apr 10, 2011

Im just not aware of compelling data that says patients intubated with midazolam are consistently at high risk for MI and so on from catecholamine dump versus other agents. Much of the data I've seen actually tells a different story regarding myocardial depression and haemodynamic changes such as hypotension. We are talking about induction doses of midazolam yes?

No, I was trying to make a distinction between induction doses (high dose) and regular dosing of Versed. Most people outside of those that don't intubate on a regular basis think giving 2-5mg of Versed is a high enough dose of Versed to use as the sole intubation drug.

I think we are on the same page. I understand what you are saying now.

GilaRRT · Apr 11, 2011

Okay, I am not sure what dose the OP is using, but I agree many people are using procedural sedation doses instead of induction doses. yeah, we are on the same page, and I absolutely think there are problems with underdosing.

qcumba · Apr 11, 2011

Ok I seeI have caused some debate, let me clarify what I mean't, We use a stat dose of 10-15mg midazolam,intubateand then once the patient is intubated and ET is secured, position checked etc we commence morphine and midazolam infusions titrated to effect, they usually run at 1mg/hr and 2-3mg/hr respectively. Now I must say that I haven't seen any patients have an MI, usually our biggest problem is hypotension.

GilaRRT · Apr 11, 2011

Ok I seeI have caused some debate, let me clarify what I mean't, We use a stat dose of 10-15mg midazolam,intubateand then once the patient is intubated and ET is secured, position checked etc we commence morphine and midazolam infusions titrated to effect, they usually run at 1mg/hr and 2-3mg/hr respectively. Now I must say that I haven't seen any patients have an MI, usually our biggest problem is hypotension.

Hypotension is not uncommon with larger doses of midazolam. The literature varies, but you are most likely looking at least 0.1 mg/kg for an induction dose. Midazolam is not really an optimal RSI induction agent IMHO. Anecdotally, I tend to favour etomidate (hypnomidate outside of the United States I believe?) for it's haemodynamic profile and rapid onset/short duration. However, I understand that most of us are not policy makers.