Intubated ED Patients are Still Not Receiving Sedation

I have previously blogged about a study demonstrating that there are ED patients being intubated and then not sedated or pain-controlled.

So it was no surprise to see a new study showing the same thing:

Watt et al. Effect of paralytic type on time to post-intubation sedative use in the emergency department (Emerg Med J 2013;30:893-895)

If the patient received sux, they got their sedatives started at the 15 minute mark (still sucks), but if they got rocuronium (they won’t be flailing about and alarming the vent) it took a mean of 27 minutes.

We can do better.

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  1. rfdsdoc says

    I had to do a RSI at 8000ft cabin due to agitated acidotic patient. long story but I chose to do a ketamine DSI due to the agitation preventing preox. as part of our CRM for the procedure the flight nurse and I got everything setup including the sedative /analgesic maintenance infusion ready and primed. as the ketamine took effect and we started preox, the nurse got a bit fixated with a fluid pump and I got worried the patient was going to start waking up before we were ready to intubate! So I started the sedative infusion myself and got it running. THE DSI went fine but it made me think on reading this blog post about perhaps this being one way to ensure maintenance sedation/analgesia is on board and running right from the time of intubation.

    You could be purist and use ketamine throughout the whole DSI and into postintubation care as infusion,

    So it would be give ketamine bolus, then start ketamine infusion, preox, tube etc.

    • says


      this may be a great way to go. simply asking for sedation and analgesia drips before you start the intubation procedure usually guarantees success as well.

    • says

      it is on the EMCrit Airway Checklist as well. It is a critical component of any intubation checklist.

      Minh’s stance is irksome not because I have any doubt he has a good handle on everything needed to perfectly perform airway management. All of us with any experience can get by without the checklist. The checklist is for the learners and other team members to gel and have a multiplication of their potential to help if shit goes bad.

    • greedylobster says

      In response to Casey,
      I dont have many intubations under my belt, however having listened to Mike Winters and Scott’s presentations and having read the referenced studies – I found it incredible (I am talking about our institution here) that not only in ED, but in the setting of ICU there is a gaping hole when it comes to post ETT analgesia and often sedation (!!!) What strikes me the most, even when you suggest/ask about analgesia – often you get the “na-h that’s Ok, don’t worry about it for now” even when there are tears welling up in patient’s eyes…
      I have personally found it incredibly helpful, when I intubate a patient in ED – I would routinely task one of the nurses with setting up a posETT infusion with clear instructions as to what we are going to use and starting doses. I find it very helpful as: one – you get this out of your mind; two – your team knows what comes after the ET is in; three – there is always a degree of excitement/healthy panic and running around and if you task team players with things you need done (sedation and analgesia, prepare NGT, IDC etc) – everyone suddenly has their role and the whole procedure becomes more concerted as people have their tasks and have the sense of importance, and last, but not least – the PATIENT is the WINNER!

  2. rfdsdoc says

    just took screen shot of your latest comment Scott to use in my debate at SMACCGOLD with Tim!
    my premise is what you state. Those with experience can manage without checklist for emergency airway interventions.

    I totally support the use of checklists for learners and those who only need to occasionally intubate.
    and to be honest…well lets say checklists are a good idea in general. But i dont want to give Tim any more ammunition against my debate strategy!

  3. Jonathan says

    This is written from the perspective of a flight nurse and ER nurse:

    In addition to the paralytics at the initial intubation, several times in the hospital and pre-hospital setting I have seen practitioners opt to re-paralyze when patients get agitated or when overbreathing the ventilator rather than rethink their sedation strategy. I recently asked an Intensivist to forego a dose of Nimbex for an intubated hypotensive patient with a respiratory rate of 36 despite fentanyl and midazolam infusions, and I opted instead to use Ketamine with great success. I suppose the moral of the story is to think outside of the “normal” sedation strategy if the usual arsenal is falling short of your therapeutic goals.

  4. CR says

    All too often folks are intubated in the ED and are not given adequate sedation. As a critical care doc, I see this more than I would like to. When I was training the ED guys were usually spot on and the patients came up sedated. I have been traveling for five years and have been in 17 hospital thus gotten admits from 17 ED — large and small hospitals and variance of work is amazing. The issue is that education has gone out the window. Docs are too busy with paperwork, charting, and administrative crap to keep up to speed with changes. I commend you on having this blog but fear not enough people avail themselves of reading sites like this. We need to fix simple nuts and bolts issues in my opinion. Thanks for posting this. Folks read articles and think they get educated…when we still can’t do simple stuff. We all learned to sedate folks, so why all the variance of practice? Ugh.

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