July 27, 2012

3 Simple Rules to Avoid Torture

Don't do this.
Scott Weingart has another great but unfortunately sad post about post-intubation sedation.

The fact that this needs to be discussed at all makes me sad, which inspired me to share some pearls.

Not sure which of these I learned from Scott Weingart specifically (most likely: all of them). Special thanks to Scott for teaching me to fix patients without torturing them.

(nb - I'm going to use the terms "sedation" and "sedative" even though the first line should be analgesia. see EMCrit 21)

Here are 3 simple things that I do to not torture my patient:

1. Sedation is an RSI med

Ask for your sedative the same time you ask for your RSI meds.

If you're planning on intubating a patient, it should be no surprise to you that very soon you will have an intubated patient that requires sedation.

This is easy.

Sample interaction:

"Can you please get me 100 mg of roc, 100 mg of ketamine, and a fentanyl drip?"

2. Paralysis is NOT sedation

Just because your patient is sitting there calmly does not mean they are comfortable, particularly if you have given them a paralytic. This is relevant in 2 ways.

a) If you used roc to intubate, your patient is paralyzed for some time, so remember to sedate them.

b) Don't use paralytics as post-intubation sedation.

"10 of vec" is NOT a sedative. Don't use it. Forget that it exists. It makes your life easier but is unequivocally terrible.

I won't say "never" because there are a few RARE circumstances where paralysis may be necessary in the intubated patient. Namely, this is at the very end of the algorithm for the ultra-severe asthmatic, and certain special circumstances of ventilator-dyssynchrony. But in both of these cases, your patient should be sedated FIRST and DURING paralysis.

If you're not really sure what I'm talking about here (and even if you are) then make sure you talk to an intensivist before you use paralytics here; or (more likely): NEVER use paralytics for the already-intubated patient.

3. Don't use pain as a pressor

see: EMCrit - Pain and Terror as Effective Pressors

The ETT comes with sedative, period. Treat the blood pressure as you would anyone else -- resuscitate, add pressors, or dial down PEEP (you actually have one more option than in the non-intubated patient).

2 options to maintain MAP in the hypotensive intubated patient:

a) no pressor, no sedative, yes torture

b) yes pressor, yes sedative, no torture

If you're not sure which of these is a better idea then... well I don't have a polite way to end this sentence.


  1. I would also recommend either getting the drip set up prior to the procedure or get a syringe full of sedation meds in your pocket (anticipating the immediate post-intubation period frenzy). And if thats too much to remember for juniors, they should try to break down the intubation sequence into distinct steps (pre-intubation collection of thoughts/equipment/meds, intubation, immediate post-intubation, stable on vent) with obvious thanks to Strayer on that...

    1. absolutely. don't ask for your intubation meds without setting up the post-intubation drip!

  2. Thoughts on when people say an intubated GCS of 3 doesn't need meds. Especially in transport. Thoughts!? I think it is still cruel.

    1. Agreed completely. We have no idea what's going in there, I always add on sedation even if completely unresponsive.