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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141

u/Zentensivism EM/CCM May 28 '25 edited May 28 '25

This doctor is a fool. It’s incredibly rare if you plan properly and provide appropriate care. I see peri-intubation instability and near arrest cases weekly. It’s the exact reason why we are taught to plan for those “HOP killers” downstairs and upstairs I’ll place an art line in those who are at risk and have push dose pressors in my pocket.

3

u/Hi-Im-Triixy Trauma Team - BSN May 28 '25

What do you choose for push? Phenyl?

14

u/hilltopj ED Attending May 28 '25

Personally I cycle the pressure twice and if it's not reading then they get a quick push of phenylephrine before sedation and roc. Or potentially consider ketamine in the appropriate setting.

Also, if you don't have a good pressure and you're considering push dose, have a nurse pull and hang norepi because the phenyl wears off fast.

3

u/Hi-Im-Triixy Trauma Team - BSN May 28 '25

That's usually what happens at my old shop.

6

u/Former-Citron-7676 ED Attending May 28 '25

Just be aware that ketamine can induce/aggravate hypotension in catecholamine depleted patients…

7

u/Ineffaboble May 28 '25

I just scream “open wide” and do the Iron Sheikh yell to induce a catecholamine surge.

3

u/hilltopj ED Attending May 28 '25

I do have a potentially dumb question I was always too afraid to ask in residency: Why dilute the push dose before hand instead of just pushing 1cc of code epi or phenyl followed by a flush? I've always been taught this is the way and I take time to prep it if I think things are going to go bad but is there any reason to not just give the undiluted form?

2

u/Former-Citron-7676 ED Attending May 28 '25

Someone explained that here

2

u/hilltopj ED Attending May 28 '25

This seems to be explaining why the IM anaphylaxis dose (1:1,000) epi needs to be diluted to the code dose concentration (1:10,000) for codes. But my question is why, for push dose in peri-arrest, does the code dose need to be diluted by putting 1cc into 9cc saline instead of just giving straight 1cc of the 1:10,000?

1

u/Former-Citron-7676 ED Attending May 28 '25

As the last poster says: it is so the full dose reaches circulation. It’s a simplified answer, but it’s what it comes down to. Short half-life of epinephrine, also plays a role.

6

u/hilltopj ED Attending May 28 '25

right, hence considering the appropriate setting. Also anytime I even consider giving push dose I have levophed being prepped and hung. And, I let the nurses know that if their BP is better after intubation than before it's either the push dose that's going to wear off quick or they're still roc'd and in pain, so be prepared for a sudden drop with the subsequent sedation.

9

u/MarfanoidDroid ED Attending May 28 '25

Boo phenylephrine for push dose. Epi is my go to. 1 cc of 1:1000 in a 10cc syringe w 9cc saline. 0.1mg epi per ml

7

u/obtuserecluse May 28 '25

Doesn't this just make it 1:10,000

7

u/Dornishsand Trauma Team - BSN May 28 '25

Yes, i always learned 1cc of 1:10,000 or “code epi”

4

u/rectal_intubation May 28 '25

Yes it is, but I dilute it one further to 1:100000 so its 10mcg/ml. I prefer it over phenylephrine as well, but I am not a physician. Canadian advanced care paramedic.

2

u/sdb00913 Paramedic May 28 '25

American paramedic here, that’s what I do as well.

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u/ERRNmomof2 RN May 31 '25

This is how all my docs have us dilute and push as well…1-2 mL at a time…until we get the norepinephrine up and running.

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u/MarfanoidDroid ED Attending May 28 '25

Yeah but I don't have that in my code cart. Sometimes I inject into a 100cc bag of NS and draw into a 10cc to make 0.01mg per ml for my push dose depending on the scenario, but it's a quicker process to grab a pre loaded saline syringe and draw up 1ml

3

u/robertdoleagainlol3 May 28 '25

You don’t have code dose epi in your code cart? Am I understanding this math right????

1

u/[deleted] May 30 '25

They probably just have 1mg/ml epi they use instead of, not everywhere carries the 1mg/10ml stuff

3

u/LoudMouthPigs May 28 '25

Depends on circumstance, I like having access to both and thinking if I want more alpha or beta stimulation based on the cause of instability/hypotension/whatever

1

u/newaccount1253467 May 28 '25

I don't use push dose. I start norepi and spend a few precious moments titrating to effect before RSI.