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/NarKoseName]

How did the patient present in the ER? Any diagnosis would be helpful. What was the reason for the RSI? Maybe a physiologically difficult airway?

„peri-intubation arrest is incredibly rare“ holds truth for elective surgery but not for the acute/emergency setting.

[u/hilltopj → u/NarKoseName]

My worst was a guy whose family forced him to come in after 4-5 days of chest pain in respiratory distress. Flash pulmonary edema after likely massive MI with evidence of myocardial rupture. Pressures in the toilet, awake but struggling. Started fighting the bipap and his sats tanked. Within minutes he went from tenuous to push dose > push dose >intubate >2 pressors.

[u/Ineffaboble → u/hilltopj]

That was very similar to this patient, except that she was stable hemodynamically pre-intubation. Just her sats were abysmal. I definitely thought myocarditis (prodrome of viral sounding illness) but her troponin was nl (which hadn't even resulted by the time I intubated her).

[u/Negative_Way8350 → u/Ineffaboble]

It sounds like she was teetering on the edge of losing her cardiac output anyway. And unfortunately intubation can push them over that edge even as we know their airway needs to be secured.

Sounds like a classic "ED are shitty, sloppy, stupid providers" complaint instead of coming downstairs to see what we deal with day in and day out.

[u/MaximsDecimsMeridius → u/Ineffaboble]

I've been there before with nurses and RT all around badgering me to tube someone with garbage sats and a bp of shit/worse rather than resuscitate first. Usually I'll crank the o2 valve as wide as it goes, also put on nasal cannula if the sats are particularly crappy, start pressors, try and get a quick vbg and istat, and i can usually bag them to >90% while all that is going on. Sometimes everyone has to stand around watching RT bag them for a few long minutes. And every time I dont immediately cram the ett down I have to repeatedly tell them it's not a great idea to try to tube someone whose not optimized if you can help it unless they hankering to code someone. I think they just don't like standing around while the sats slowly tick up. Its a lot easier to prevent a code than it is fix one.

[u/hilltopj → u/Ineffaboble]

That's a shitty situation and even worse when you get some ass trying to backseat drive after the fact! I'm sorry that happened to you!

[u/irelli → u/Ineffaboble]

It sounds like they needed bipap and an aggressive amount of nitro based on what you're saying.

[u/hilltopj → u/irelli]

Bipap and aggressive nitro for a guy already on bipap with garbage pressures?

[u/irelli → u/hilltopj]

OP called it flash pulm and said everything was good other than the saturation.

Either they were incorrect and it wasn't flash pulm, or they were and the answer was bipap and nitro.

It sounds like this patient died because of hypoxia, not hypoperfusion. They started intubating when the sats were in the 60s and the patient went bradycardic.

[u/hilltopj → u/irelli]

OP says elsewhere the pt wouldn't have tolerated bipap. And "stable" blood pressure doesn't necessarily mean high enough to tolerate aggressive nitro. Certainly might have been worth considering some nitro, but as has been pointed out elsewhere, we don't know the situation or the specifics so our opinions on how the patient should have been handled are useless

[u/irelli → u/hilltopj]

There's no such thing if you're planning on intubating. If your patient is hypoxemic and you think the cause is flash pulm, you put them on bipap. Altered and can't protect their airway? Doesn't matter, you're about to intubate. Agitated from hypoxemia? Doesn't matter, mod sed for pre oxygenation

This was a crash intubation that - based on what information was provided - should have been a delayed sequence intubation with bipap as your pre oxygenation+ nitro in the mean time. These guys turn around fast so might even been able to avoid intubating. But even if not, at least it's a safe intubation.

I get that it's easy for me to say this in retrospect, but tjat doesn't make it less true.

Also if their blood pressure isn't dumb high, odds are it isn't flash pulm. I won't say never, but you're more likely in cardiogenic shock than flash