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.

243 Upvotes
  • permalink
  • reddit

98% Upvoted

148 comments sorted by

View all comments

30

u/NarKoseName May 28 '25

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.

11

u/hilltopj ED Attending May 28 '25

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.

3

u/Ineffaboble May 28 '25

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).

5

u/hilltopj ED Attending May 28 '25

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!