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Thu May 15 15:48:38 BST 2008

Bill, I totally agree with you that waiting out the "post-ictal"  period is the standard, that's why I am talking about it - I say it should be the standard to iuntubate and prevent aspiration.
Let me ask you: how is it you're saying that airway reflexes are not abolished ?

Proving that aspiration happened only in hospital and not prior to admission for a seizure is very difficult.
An aspiration can always be faulted on the first out-of-hospital seizure.

 Ivan Hronek MD                                                                              
SFMC, Los Angeles, CA                                                
http://health.groups.yahoo.com/group/Anesthideas/                           Nobody cares if you can't dance well. Just get up and dance. Great dancers are not great because of their technique. They are great because of their passion. Martha Graham
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----- Original Message ----
From: Will Owens <brain_hanger at hotmail.com>
To: Ivan Hronek <ivanhronek at yahoo.com>; ccm-l at ccm-l.org; trauma-list at trauma.org
Cc: anesthideas at yahoogroups.com
Sent: Thursday, May 15, 2008 6:24:02 AM
Subject: RE: [ccm-l] Intubation post GM seizure: when ?

I think that waiting out a post-ictal period is a standard practice--I generally don't intubate unless it's status epilepticus.  Sit the patient up, prevent him from falling, and watch him closely.  Airway protective reflexes are not abolished, and you may induce vomiting either with laryngoscopy or with "checking the gag reflex"--that's why I tell the residents not to stick tongue depressers in the back of stuporous patients' mouths.

Do you have any evidence that this is unsafe, since I would venture that most ED/ICU physicians are content to wait and see if the post-ictal phase resolves?

***********************************************
William Owens, MD
Assistant Professor of Medicine
Division of Pulmonary and Critical Care Medicine
University of South Carolina School of Medicine
8 RMP, Suite 410
Columbia, SC 29203
(803) 799-5022

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Date: Wed, 14 May 2008 22:48:08 -0700
From: ivanhronek at yahoo.com
To: ccm-l at ccm-l.org; trauma-list at trauma.org
CC: Anesthideas at yahoogroups.com
Subject: [ccm-l] Intubation post GM seizure: when ?

Just to repeat and be clear to those who didn;t see the previous postings, I am doubting we know what we are doing when we follow the teaching that is is OK to leave comatose "post-ictal" patients after a seizure non-intubated as to the risk of pulmonary aspiration.

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I am just cutting a few sentences from this online recommendation on the management of seizures in the ER:
http://www.emedicine.com/neuro/topic694.htm

During the postictal period, patients often are confused or lethargic. This usually lasts 20-30 minutes.

20 - 30 min with an unprotected airway ? That's pretty long !

As patients are not breathing during a generalized tonic-clinic seizure, they are not at high risk for aspiration until the event ends. Immediately following the seizure, patients usually take a deep breath. 

                                      ......then  no further mention of intubation... ..until suddenly:

If the patient continues to be in status epilepticus after receiving 30 mg PE/kg of fosphenytoin, several options are available. One is to load the patient with 25 mg/kg of IV valproic acid. If this too fails, all the remaining options carry a high risk of respiratory depression. Therefore, the patient should be intubated at this point, if he or she has not been intubated already. 

?? So we got no recommendation to intubate the patient and suddenly we're told we may have intubated the patient already ? Again, no criteria for intubation given; the aurthor is just not clear about it, that's what it is.
________________________________

NYU (my alma) says: http://www.med.nyu.edu/pediatrics/emergency/cpem/trippals/16SEIZE.PDF

If the airway is patent without positioning or suctioning and there is no history or evidence of
trauma, place the patient in the left lateral decubitus position (recovery position, see figure A35).This will reduce the risk of aspiration if emesis occurs. 
Aha ! So there is a risk of aspiration , right ?

Endotracheal intubation should be considered only if BLS actions, including placement of anasopharyngeal airway adjunct, are ineffective. Consult medical control or regional protocols.

Can you tell me what is medical control or regional protocol please ?
Same thing: the author has no clear idea about what to do with the airway, despite the fact that he knows aspiration is possible.

I am getting tired...but as you can see one can find many examples of the same...we have no idea where this recommendation not to intubate "post-ictal" patients came from and why it is all over all the textbooks (please tell me it is not so if you can !).

We need to do awya with this ilogical nonsense and start intubating these patients despite the fact that it is only for a short period of time in most. We will be able to take better control of their airway, prevent aspiration, give them the medication they need without fear of respiratory depression ans again aspiration from sleepiness. They may be asleep a little longer than without intubation but they sill be safer. That's why they come to the hospital after all right ? They didn;t come to just lie there and aspirate did they.

Thanks, yours, 

Ivan Hronek MD                                                                              SFMC, Los Angeles, CA                                                
http://health.groups.yahoo.com/group/Anesthideas/                           
Nobody cares if you can't dance well. Just get up and dance. Great dancers are not great because of their technique. They are great because of their passion. Martha Graham

________________________________

Confidentiality Notice: This transmission and any attached documents may be confidential and contain information protected by State and Federal Medical Privacy statutes and is legally privileged. They are intended for use only by the addressee. If you are not the intended recipient of this transmission, or an agent of the intended recipient, you are prohibited from reading, disclosing, printing, saving, copying, using, or otherwise disseminating any information contained in this transmission. If you received this transmission in error, please accept our apologies and notify me at  ivanhronek at yahoo.comand delete the entire message and its attachments. Thank you. Disclaimer: this message contains the personal views of the author. The author will not be responsible in any way for procedures or approaches perfomed in the way suggested in this note. 

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----- Original Message ----
From: "Patterson, Robert" <Rpatters at nemours.org>
To: Ivan Hronek <ivanhronek at yahoo.com>; ccm-l at ccm-l.org
Sent: Wednesday, May 14, 2008 10:03:00 PM
Subject: RE: [ccm-l] Intubation post GM seizure: when ?

I'm presuming an uncomplicated and resolved seizure of non-traumatic origin.  If a kid is breathing adequately and maintaining his / her own airway, I am as likely to induce aspiration with my RSI as I am to prevent it.  The altered mental status is generally transient.  This happens multiple times a year with febrile seizures or breakthrough seizures in kids with epilepsy.  If they meet criteria for respiratory failure, I intubate them; otherwise they are observed in a monitored setting (emergency department to step-down unit) until they wake up.  

-rob
Robert Patterson, MD, FAAP
Department of Pediatric Critical Care
Nemours Children's Clinic
Pensacola, Florida
rpatterson at nemours.org
850-473-4511 

________________________________
From: ccm-l-bounces at ccm-l.org [mailto:ccm-l-bounces at ccm-l.org] On Behalf Of Ivan Hronek
Sent: Wednesday, May 14, 2008 9:55 PM
To: ccm-l at ccm-l.org
Subject: [ccm-l] Intubation post GM seizure: when ?

Robert, let me ask you please:

so there's a kid that comes in post-seizure post-ictal (=not awake) with a full stomach and you don't intubate the kid ? You're not afraid of aspiration ? How come ?

 Ivan Hronek MD                                                                              SFMC, Los Angeles, CA                                                
http://health.groups.yahoo.com/group/Anesthideas/                           
Nobody cares if you can't dance well. Just get up and dance. Great dancers are not great because of their technique. They are great because of their passion. Martha Graham

________________________________

Confidentiality Notice: This transmission and any attached documents may be confidential and contain information protected by State and Federal Medical Privacy statutes and is legally privileged. They are intended for use only by the addressee. If you are not the intended recipient of this transmission, or an agent of the intended recipient, you are prohibited from reading, disclosing, printing, saving, copying, using, or otherwise disseminating any information contained in this transmission. If you received this transmission in error, please accept our apologies and notify me at  ivanhronek at yahoo.comand delete the entire message and its attachments. Thank you. Disclaimer: this message contains the personal views of the author. The author will not be responsible in any way for procedures or approaches perfomed in the way suggested in this note. 

________________________________

----- Original Message ----
From: "Patterson, Robert" <Rpatters at nemours.org>
To: Ivan Hronek <ivanhronek at yahoo.com>
Cc: ccm-l at ccm-l.org
Sent: Wednesday, May 14, 2008 7:35:41 PM
Subject: RE: [ccm-l] ETT post GM seizure: when ?

I would usually decide to intubate based on a clinical diagnosis of respiratory failure, potentially after a failed attempt at non-invasive mechanical ventilation since this tends to be self-limited.  I can not recall a time I intubated to prevent aspiration.

-rob
Robert Patterson, MD, FAAP
Department of Pediatric Critical Care
Nemours Children's Clinic
Pensacola, Florida
rpatterson at nemours.org
850-473-4511 

________________________________
From: ccm-l-bounces at ccm-l.org [mailto:ccm-l-bounces at ccm-l.org] On Behalf Of Ivan Hronek
Sent: Tuesday, May 13, 2008 8:03 PM
To: trauma-list at trauma.org
Cc: csen_international at csen.com; Anesthideas at yahoogroups.com; ccm-l at ccm-l.org
Subject: [ccm-l] ETT post GM seizure: when ?

Let's try and vote for the best answer to the following question (please b brief if poss.):

What should we go by in the "post-ictal" state after a GM seizure when deciding to intubate to prevent aspiration ? Time (how long) ? GCS ? Reaction to antiseizure drugs ? 6th sense ?

________________________________

Some pertinent literature:

Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 6th ed.:
 Preparation should be made for endotracheal intubation in case anticonvulsant drugs fail to terminate the seizure.

 http://www.merck.com/mmpe/sec16/ch214/ch214a.html
 Ivan Hronek MD                                                                              SFMC, Los Angeles, CA                                                
http://health.groups.yahoo.com/group/Anesthideas/                           

An appeaser is one who feeds a crocodile, hoping it will eat him last.        
Winston Churchill                                                                                                

________________________________

Confidentiality Notice: This transmission and any attached documents may be confidential and contain information protected by State and Federal Medical Privacy statutes and is legally privileged. They are intended for use only by the addressee. If you are not the intended recipient of this transmission, or an agent of the intended recipient, you are prohibited from reading, disclosing, printing, saving, copying, using, or otherwise disseminating any information contained in this transmission. If you received this transmission in error, please accept our apologies and notify me at  ivanhronek at yahoo.comand delete the entire message and its attachments. Thank you. Disclaimer: this message contains the personal views of the author. The author will not be responsible in any way for procedures or approaches perfomed in the way suggested in this note. 

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Intubation post GM seizure: when ?