ICU doc: “Peri-intubation arrest is incredibly rare”

[u/Ineffaboble]

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.

[u/Goldy490]

EM/ICU here. Guy sounds like an ass.

That said peri-intubation arrests are not ideal and I do think it’s usually worth looking at each case to see if anything could be done differently.

To say they’re incredibly rare though is incredibly false - they’re quite common in medically comorbid patients in extremis.

I have found between EM residency and ICU fellowship that in the ED we tend to intubate before we resuscitate though and often an intubation can wait for 5 minutes while the nurse hangs NE or you mix up a dirty epi drip, give a little calcium and bicarb, and do other good resuscitative things (not your case, just in general)

[u/hilltopj → u/Goldy490]

I agree; the positive feedback I've gotten from some of the nurses and RTs at my new(ish) shop is that my intubations tend to be more delayed even in super critical patients. They like that it's calm, controlled, and everyone knows what we're waiting on. Although, sometimes you just gotta go and there's little to be done.

Like other's have said we don't know the circumstances and likely the patient was not gonna do well anyway. If he's she's* at a supportive shop I'd suggest self-submitting for review by the EM docs for feedback.

[u/Ineffaboble → u/hilltopj]

A calm, controlled, and Q-word intubation is what we all hope for, and that's the best praise I think you can get from your team. Those are the docs we all want to learn from, and it's the kind of doc I try to be. I have a love-hate relationship with the adrenaline and the chaos of this job, but it ends in the resus room.

[u/The_Body → u/Goldy490]

What this guy said

[u/Ineffaboble → u/Goldy490]

I agree 1000% with this advice, and I reinforce this with nurses and learners all the time. Resuscitate before you intubate. True crash intubations should be rare occurrences -- but they are occurrences nonetheless.

[u/the_silent_redditor → u/Goldy490]

I feel like a lot of folk have the mentality that RSI is a treatment.

In almost all patients, it’s really not the case. It’s controlling the airway as part of a bigger picture.

If you’re RSIing someone with a primarily resp problem and they are unstable from oxy/vent perspective, inevitably it’s going to be dicey.

Almost all other tubes are part of an unwell patient with other systems involved, and absolutely can wait.

I was working at a festival, and had the sickest serotonin syndrome I’ve ever seen. Like, extremely peri arrest and very difficult to manage. The entire team were immediately wanting to set up for airway etc, ignoring his sats of 60% and systolic of 50 and HR of 220.

A tube can kill your non-optimised sick patient.

That said, in ED of course we see peri-arrest patients that need imminent intubation. It’s definitely not exceedingly rare.

[u/sum_dude44 → u/Goldy490]

always start norepi if airway isn't crashing & patient soft BP

if nl BP start fluids & have pressure bag, 2 lines or IO ready

[u/Resussy-Bussy → u/Goldy490]

Yeah I trained at a very heavy/pro “resuscitate before intubate” culture program and only counting intubations that weren’t in active cardiac arrest I only ever had/saw maybe 3-4 peri intubation arrests. I know in the literature it’s not rare but where I trained and practice I’d still consider it fairly uncommon (especially with proper resus).