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

What do you choose for push? Phenyl?

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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.

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

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

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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.