All Paramedics Must Review: Intubation and Post-Intubation Care

ALS and RSI Providers-

While at the National Association of EMS Physicians Meeting this past week there were a few things that I thought I would share.  All are congruent with our current protocols, but at the same time, each of these are quite nuanced.  I would strongly encourage you to be familiar with the following as you manage your patients airway, and subsequently their ventilation.   I would also hope that at the agency level, you perform focused performance improvement activities surrounding these measures.  I apologize in advance for the length of this, but felt I should give you the background as well as the recommendations.

The following is specifically related to the management of the Traumatic Brain Injury (TBI) patient. Since there is almost no data on other patient populations, the impact may be more or less, but I think it’s safe to say that these are best practices for the management of intubation, ventilation, and post-intubation sedation regardless of the reason for the patient needing it.

-A second attempt at endotracheal intubation TRIPLES mortality.  All the more important to have a first pass plan that maximizes the potential for success.

-We used to say that a single episode of hypoxia doubles mortality.  We were wrong, it probably QUADRUPLES mortality!  NO-DESAT (nasal cannula oxygenation during ETI), and effective preoxygenation are absolutely critical.  This is also probably the reason a second attempt at ETI triples mortality.

-Proper ventilation is even more critical than we previously thought.  We know that hyperventilation kills both because of cerebral vascoconstriction and decrease of cerebral blood flow, but also because of decreased venous return to the right side of the heart.  Our target remains ETCO2 of 35-45, but we now know that a SINGLE episode of hyperventilation defined as an ETCO2 of less than 32 mmHg increases mortality, and not surprisingly, with each subsequent decrease of 3 mmHg ETCO2 below 32 mmHg that mortality increases.  So not only should we be even more vigilant about ventilation rates and subsequent EtCO2, we should be making sure that when performing QI on our intubated patients, that looking at ETCO2 and ventilatory rate is part of that review.

-The issue of sedation in the intubation patient continues to come up.  First, lets keep in mind that hypotension in the head injured trauma patient is clearly bad.  We know that mortality doubles with an episode of hypotension (defined as a SBP of less than 90).  But it may be actually worse.  When you look at the association of hypotension and mortality in blunt head trauma, a systolic BP of <144 is bad.  YES! Those with a systolic pressure of <144 have a greater risk of death when controlling for other factors than those with SBP >144.  So to be clear I am NOT advocating for norepi on these folks!  What I am advocating for, is that the pendulum in post-intubation sedation may have swung too far.  We are likely over-sedating these folks, and as a result, their BP is going down, and we know that is bad for brain cells.  This is clearly the case for blunt trauma TBI patients, and may be very much the case for all our patients.  Put it another way, I can't remember the last time I saw an issue because someone DID NOT sedate someone, but the risks of sedating are likely much higher than we previously thought.  So the point is, DON'T IMMEDIATELY REACH FOR THE MIDAZOLAM after you tube someone.  A little hypertension is a good thing, so if you really want to do something, first try fentanyl alone.  If they CONTINUE to clearly be agitated and combative and that is impeding your ability to appropriately oxygenate and/or ventilate AFTER giving appropriate doses of fentanyl, THEN consider midazolam, but TITRATE in 2.5 mg aliquots.  DO NOT GIVE MIDAZOLAM EMPIRICALLY “JUST IN CASE”.  We probably gave a little too much freedom in our protocols to hit them with 5 at a time in the post intubation sedation environment because the more I read, the more we may be doing harm.

-I have heard a number of providers talk about permissive hypotension in trauma patients.  First, keep in mind that permissive hypotension MAY have a benefit but ONLY in those that it was studied in - penetrating trauma WITHOUT head injury.  All of the studies on permissive hypotension were in that group.  Fortunately, we VERY RARELY have patients that meet that criteria.  We deal with blunt trauma the vast majority of the time, and hypotension is decidedly BAD.  Don't do it (read the last bullet if you don't understand why I am saying that).

That's it for now...I hope this is helpful and please feel free to contact me with questions or concerns.

Jeremy

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Jeremy T. Cushman, MD, MS, EMT-P, FACEP

Associate Professor and Chief, Division of Prehospital Medicine

Department of Emergency Medicine, University of Rochester

Monroe County and City of Rochester EMS Medical Director

Monroe-Livingston Regional EMS Medical Director

Phone: 585.463.2900  Fax: 585.473.3516 Page: 585.529.0906

Jeremy_Cushman@urmc.rochester.edu

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