Intubating the combative patient

How many times have I been asked by the trauma surgeons to see a trauma patient for respiratory failure? The reason for intubation and ventilatory support – being combative and non-cooperative.

Intubating, sedating and sometimes even paralyzing a combative patient is an established practice. Combative patients are dangerous to themselves and to the medical staff. Clinical and radiological evaluation of these patients is difficult as well. Asking “What is hurting, Sir” if the patient is kicking, screaming, biting and spitting is unlikely to yield any clinically useful information. Getting an extremely agitated patient to a CT scanner could be a great challenge.

Most of those patients end up on a ventilator only temporarily. Once the effects of alcohol and drugs that had been taken wears off the patient is taken off the ventilator. In some cases serious injuries could be found that would require extended ventilatory support.

Intubation or insertion of a breathing tube could be associated with complications. Especially when performed urgently and in the field conditions, the patient can experience hypoxemia (low oxygen level), aspiration of gastric contents into the lungs and damage to the vocal cords. Sedatives and paralytics used for intubation can interfere with the neurological exam and clinical evaluation.

A study published in the June issue of the Journal of Trauma compares outcomes between two groups of patients. The patients in the first group were intubated for combativeness. The patients in the second group were similar patients in all aspects, yet they were not intubated.

The results of this study are not surprising. When intubated for combativeness, patients had longer hospital stays, more frequent respiratory complications and poorer discharge status.

The authors proposed that combativeness in some patients could be a manifestation of a traumatic brain injury even if a CT head was negative for acute pathology. It is true – some patients with head injury could have an unremarkable CT scans.

The authors also suggested using sedating medications like Haldol and Benzodiazepines to control agitation and avoid intubation.

In my personal experience, many combative patients “fail” a less radical sedation prior to being put on a ventilator.

Interestingly, even though this is a very recently printed article, it was submitted for publication back in July of 2006. Using a newer drug Precedex might be helpful to control extreme agitation. Next time I get asked to see a patient with “respiratory failure from being obnoxious” I will suggest it to the surgeon.

Ralph Gordon is a critical care physician who blogs at realICU.

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  • BladeDoc

    Seriously suggesting that I call Pharmacy to get a Precedex drip sent up to “give it a try” when I’ve got a nurse ducking punches and trying to hold the tenuous IV in while a resident and medical student holds onto each arm and leg would likely get you the SECOND dose of Succinylcholine administered that visit.

    • BladeDoc

      Oh, and I guess I have to add that the above comment was in jest. I haven’t stuck anyone with anything since my second year of residency — and that was an accident. really.

  • drjebj

    Precedex sounds very expensive. Rather than lapse into my sarcastic cost control voice may I suggest that MORPHINE is God’s gift to the physician with difficult patients in pain? As central pain reliever it is very calming, has a wide therapeutic index and is very reversable (and cheap.)

  • DrB

    As a current PCP and former hospitalist, this is a pet peeve of mine. In my opinion, intubation due to combativeness (Without attempted sedation via Haldol or Ativan or Morphine, etc.) is overly aggressive and not caring about the patient, or just plain assault.

    If someone is harming himself or the staff, by all means, put him down, but do it with IM or IV drugs. Don’t argue you have to deal with flailing arms and such so you can’t waste time with this…the same is true if you are moving close to the bedside in giving a paralytic and preparing to intubate.

    IF/WHEN the patient becomes so drowsy that they are having a hard time protecting their airway or even having some respiratory compromise, then you can intubate, and justifiably. Prior to that, you are forcing someone into an unneccessary procedure that could kill them at worst, but at best buys them a trip to the ICU and thousands in extra costs…all because you didn’t take the time to try some IM drugs and wrist restraints? Give me a break.

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