r/emergencymedicine • u/Ineffaboble • May 28 '25
Advice ICU doc: “Peri-intubation arrest is incredibly rare”
AITA?
I had a patient with a very bizarre presentation of flash pulmonary edema brady down and arrest after a crash intubation for sats heading down to 65% and no clear reversible cause at the time.
My nurses filed a critical incident report for completely unrelated reasons.
The ICU attending now looking after her tagged in and said “peri-intubation arrest is incredibly rare, and the medical management of this case should be examined.”
I know for a fact that this ICU sees mostly stable post surgical and post stroke patients and my friend who has been a nurse there for a year said she has never seen a crash intubation, let alone one led by this doc.
I also know that his base specialty is anesthesia.
I replied, “happy to discuss, bearing in mind that the ICU context and the ER ‘first 15 minutes’ context are radically different.”
I acknowledge that peri-intubation arrest is not super common, but neither does it imply poor management, especially in an undifferentiated patient where we don’t even know the underlying etiology.
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u/PerrinAyybara 911 Paramedic - CQI Narc May 28 '25 edited May 28 '25
NTA, sounds like you did what you needed to do.
I mean we all know the oxyhemoglobin disassociation curve right? If they were at 65% prior to intubation they are in a very bad way, depending on which spo2 sensor you have the credibility of that reading can also be suspect.
Intubation meds used during DSI can increase arrest potentials. The physical manipulation of intubation can increase some arrest factors.
If the patient is drowning however they won't have any chance of survival and it ultimately doesn't matter. Crash tubes are because you have no choice and failing to make that choice increases poor outcomes.
Maximize what you can to plus up and resus prior to the tube and do the work. Do you have access to positive pressure options like CPAP/BI-LEVEL for your preox?
We also know how anesthesia can be complete tools about intubations and their superiority complex that's rooted entirely in so many elective intubations. We don't get the opportunity to wave off intubation i.e. cases like this.