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Fri May 16 14:54:24 BST 2008

John/Rob,

Agreed, wish I could have put it so well.  Bounced this off our Chair of
Anesthesia and he said pretty much the same thing.

Marc

Marc C. Restuccia
Medical Director 
Life Flight/MDAccess/Worcester EMS
508-421-1468
restuccm at ummhc.org

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Robert Smith
Sent: Friday, May 16, 2008 8:21 AM
To: 'Trauma &amp; Critical Care mailing list'
Subject: RE: Intubation post GM seizure: when ?

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
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If you are not the intended recipient of this transmission, or an agent
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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 
Medicine> 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
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prohibited from reading, disclosing, printing, saving, copying, using,
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transmission. If you received this transmission in error, please accept
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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
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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 ?