the worst intubation

Nurses General Nursing

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I'm shocked by this intubation I saw at clinical earlier. They didn't give the patient

succinylcholine or propofol or anything before they tried to intubate him, and he was fighting. The intern and then the resident tried and failed five times to get a tube in him and they bloodied up his trachea before someone got a tube in. They didn't use aseptic technique. My professor said it was the worst intubation she's seen. I'm just feeling upset that they didn't sedate him and he was struggling, they waited until they finally got the tube in and then gave him 0.5 of Ativan. I can't say what hospital it is, but I hope to God I never get taken there. Have you seen anything like this?

Specializes in ED, Pedi Vasc access, Paramedic serving 6 towns.

Sounds terrible, but like other posters have said that intubation is not aseptic.

Also if the clinicians had any concern that the patient was going to be difficult to intubation from obesity, short neck, physical assessment such as thyromental distance, throat cancer or anything else that may distort the throat they may have been hesitant to given paralytics or heavy sedation. If they paralyzed and sedated or just heavily sedated a patient and could not get the tube or ventilate them adequately by BVM, you end up with a dead patient! Intubation is not always easy!

Instead of judging the clinicians, next time ask them questions once it is appropriate, and learn!

HPRN

never seen ativan given in intubation process... unless they do that in other hospitals

Specializes in Emergency, Telemetry, Transplant.
Someone asked why they didn't call the anesthesiologist stat, and they said that they don't do that at this hospital.

For me, that is actually the worst part of the situation.

Intubations are not always pretty--in fact, most aren't. Particularly difficult airways--for example, with angioedema--can be particularly traumatic for the patient. In addition, they rarely want to sedate/paralyze an individual with such a difficulty airway in case they aren't able to get it quickly.

The reason the quote above is problematic--anesthesia has equipment and other tricks that are not available to the ED physicians. In my hospital, anesthesia is called down before any intubation that is likely to be quite difficult (again, angioedema, hx of throat CA/surgery, need for a trach previously, etc.).

Specializes in Anesthesia, ICU, PCU.

Here's a somewhat dark but realistic thought: Suppose they called anesthesia before trying once and got it on the first time. How else are these residents going to get better at difficult airways unless they get practical experience? Suppose this one patient's misery will result in skill that saves lives in the future?

Seems like your nursing instructor would have been able to discuss this, and give rationales for not paralyzing or sedating the patient. Missed teaching opportunity.

This only applies if the instructor has any experience in witnessing or assisting in intubation. As a critical care nurse I saw bazillions of them, but I assisted a med/surg instructor whose basic experience and expertise was psych when i was a critical care clinical specialist, and she didn't know anything about it at all. Even many med/surg staff nurses have never seen one, or maybe only one or two.

Morals of the story: Always call an anesthesiologist or nurse anesthetist if you're in a hospital. If out of hospital, a paramedic (not an EMT). If awake intubation is necessary, there's usually time for a quick squirt of topical anesthetic or q-tips inserted in a nose. That can make it slick and easy for an experienced anesthesia provider.

Specializes in SICU, trauma, neuro.

Without knowing his history, I'm wondering if there was a safety issue with giving him sedation first? As for succinylcholine, if this was a difficult intubation they might have opted not to paralyze him, since it would prevent any respiratory effort during what could be several attempts. Plus if he couldn't have sedation that would be horribly cruel to paralyze him.

Hugs...some of this stuff is difficult to watch!

Here's a somewhat dark but realistic thought: Suppose they called anesthesia before trying once and got it on the first time. How else are these residents going to get better at difficult airways unless they get practical experience? Suppose this one patient's misery will result in skill that saves lives in the future?

The answer is they probably haven't seen a lot of them either, and did most of their intubation practice in the OR with an asleep patient or the lab with a dead one. They should stay and watch somebody better handle the difficult procedure and learn something about how to do it better next time themselves.

Specializes in Emergency Department.
This only applies if the instructor has any experience in witnessing or assisting in intubation. As a critical care nurse I saw bazillions of them, but I assisted a med/surg instructor whose basic experience and expertise was psych when i was a critical care clinical specialist, and she didn't know anything about it at all. Even many med/surg staff nurses have never seen one, or maybe only one or two.

Morals of the story: Always call an anesthesiologist or nurse anesthetist if you're in a hospital. If out of hospital, a paramedic (not an EMT). If awake intubation is necessary, there's usually time for a quick squirt of topical anesthetic or q-tips inserted in a nose. That can make it slick and easy for an experienced anesthesia provider.

I would hope that topical anesthetics would be included in any "difficult airway" kit or be readily at hand because they do make the process a whole lot less difficult for the patient and intubationist. It's not always pain that causes problems, but a very intact gag reflex.

Specializes in ICU, LTACH, Internal Medicine.

Well, I was intubated while mostly awake (Benadryl + minimal Versed, counteracted by Epinephrine) more than once for anaphylaxis and so can say that emergency intubations are almost always hard, bloody and at the best unpleasant for both sides. Even if patient is promptly knocked off at that time, the next thing he/she will have is the worst sour throat ever for a day or so. But emergency tubes are not performed for esthetical reasons, they are done to save lives. In many of these situations, patient's condition is so precarious that everything that can drop blood pressure further, I.e. sedatives of any kind, is contraindicated. And, due to very limited information about the patient normally available for them, many emergency care providers avoid using meds with high potential for severe allergies (lidocaine), severe adverse reactions (sux, which can cause hyperkaliemia, malignant hyperthermia, aggravation of existing injuries of muscles and bones due to fasciculations and a few other equally unpleasant things) and anything of prolonged action (counting that intubation takes seconds to minutes in most cases and there may not be available resources to support the patient for God only knows how long b/o he was given "anesthesia" dose of Ativan with borderline renal function and not enough Flumazenil to keep infusion running).

People recover amazingly quickly after "worst" intubations, but not always so after waiting a couple of minutes more with inadequate Ambu bagging so that someone from anesthesia department could arrive, wait for drugs to be brought/pushed/kick in another 30 seconds of hypoxia and then push the tube down in one smooth movement and depart in glory. In emergency time is what is counted, and esthetics (and sometimes even ethics and aseptics) have to be put to rest for the sake of saving that life.

Specializes in Emergency/Cath Lab.

After attempt 2 why didn't they try a bougie? Those things are amazing.

Specializes in ICU, LTACH, Internal Medicine.

They are truly amazing if only you can see the cords. And sometimes one can't see them even with Glidescope, particularly on these nasty, bloody messes of "difficult airways".

P.S. I once heard from EMT that some of them actually prefer to do emergency tubes on patients who are not totally off and without airway anesthesia. The reasoning was that, firstly, gagging patient opens mouth wide and pushes larynx up and ahead, thus inflicting sort of self-Sellick; secondly, once tube is in place, character of cough changes immediately and so it is not necessary to wait for end-tidal CO2 and breathing sounds to confirm intubation. I wish to believe that it is not commonly held point of view:cry:

Specializes in Emergency Department.
They are truly amazing if only you can see the cords. And sometimes one can't see them even with Glidescope, particularly on these nasty, bloody messes of "difficult airways".

P.S. I once heard from EMT that some of them actually prefer to do emergency tubes on patients who are not totally off and without airway anesthesia. The reasoning was that, firstly, gagging patient opens mouth wide and pushes larynx up and ahead, thus inflicting sort of self-Sellick; secondly, once tube is in place, character of cough changes immediately and so it is not necessary to wait for end-tidal CO2 and breathing sounds to confirm intubation. I wish to believe that it is not commonly held point of view:cry:

Bougies can be used for blind intubation as well. There's a reason why there's a description of feeling the bumpy tracheal rings... Bougies and regular ETT intubation techniques are just amazing when you can see the cords.

I'm a Paramedic and I do NOT like to do emergent intubations in patients that have a strongly intact gag reflex if I can at all help it. As far as the "other" methods used to confirm placement, I don't use those. I will use some kind of EtCO2 device and I will listen...

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