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Fri May 16 13:20:37 BST 2008

John,

This is so well said. First why not try to study the "problem"? Try to get
an idea of what is the incidence of post-ictal aspiration is. 

Rob Smith

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of John Holmes
Sent: Friday, May 16, 2008 1:46 AM
To: Trauma &amp; Critical Care mailing list; Will Owens
Cc: anesthideas at yahoogroups.com; ccm-l at ccm-l.org
Subject: RE: Intubation post GM seizure: when ?

I agree with Bill.  We deal with ictal and postictal patients virtually
every day.  We do not get into problems with aspiration in the post ictal
phase.  You need to balance the risks and problems a/w RSI and intubation
(polypharmacy, the risk of inducing aspiration, missed intubation, high
dependancy nursing etc etc etc ) against the putative "advantage" of
protecting the airway. 

If you are promoting an invasive interventional therapy, then the onus is on
you to first demonstrate that (1) there is actually a real (rather than
"theoretical") problem and (2) that performing the intervention leads to
better outcomes.  

IMO we should get rid of this teaching that all GCS < 8 = ETT once and for
all.  It is probably valid in trauma.  However, in many medical and
toxicological situations, especially when there is an expectation of
reasonably rapid recovery in conscious level, then intubation may do more
harm than good.

John

Dr John L Holmes Director Emergency Medicine TrainingAMC & OLVG,
AmsterdamThe Netherlands

> Date: Thu, 15 May 2008 07:48:38 -0700> From: ivanhronek at yahoo.com> To:
brain_hanger at hotmail.com> CC: trauma-list at trauma.org;
Anesthideas at yahoogroups.com; ccm-l at ccm-l.org> Subject: Intubation post GM
seizure: when ?> > 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> ________________________________> > Confidentiality
Notice: This transmission and any attached documents may be confidential and
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If you are not the intended recipient of this transmission, or an agent of
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suggested in this note. > ________________________________>  > > > > -----
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> > > > ________________________________>
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.> > ________________________________> > 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. > > >
________________________________> >  > > > > > ----- 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 ?