Awake and paralyzed: The frightening final minutes for an injured teen

By Bradley Dean

When Drew Hughes self-extubated himself during a hospital-to-hospital transfer in June 2013, the subsequent attempt for rapid sequence induction (RSI) proved to be fatal. While emerging from sedation and paralysis, Drew was struggling to breathe, was unfamiliar with the environment and became combative. The nurse, paramedic and respiratory therapist caring for Drew believed that reintubation was necessary and began the process.

When caring for a patient, often the first task of any health care provider, is to secure the airway. In many circumstances, health care providers use RSI to accomplish this task. The procedure of RSI has become increasingly popular in the EMS setting, but there is a great deal of controversy about the procedure's safety and efficacy. This article is not intended to advocate for, or against the procedure, but look at the procedure and appropriate sedation and paralyzation of patients during and after, performing RSI.

The "Manual of Emergency Airway Management" defines RSI as the virtually simultaneous administration, after preoxygenation, of a potent sedative agent and a rapidly acting neuromuscular blocking agent (paralytic) to facilitate rapid tracheal intubation without interposed mechanical ventilation [1]. The combination of these medications pushed in rapid sequence following adequate oxygenation is intended to create optimal intubating conditions. Selection of the appropriate sedative agent and dose most appropriate for the clinical scenario is an important component of RSI.

Appropriate sedation for intubation
When reintubating Drew, the paramedic quickly pushed a paralytic rendering him unable to move, but no sedative or induction agent was utilized. Drew was awake and paralyzed during repeated intubation attempts. Induction agents, also known as sedatives, are integral to the performance of RSI. They provide amnestic effect, blunt sympathetic responses and can improve intubating conditions for the increased probability of success on the first attempt. The anesthetic agent rapidly renders the patient unable to appreciate, respond or recall any noxious stimuli. 

Unfortunately, research shows that Drew's experience is not an isolated case of paralysis without sedation. In a study of over a million patients, only 46.4 percent received sedatives and/or opiates before intubation [2]. Another study demonstrates that patients who are successfully intubated receive inadequate analgesia following the procedure to keep them from becoming agitated or causing self-extubation [3].

While RSI has become the cornerstone of emergency airway management for intubations that are not anticipated to be difficult, the assessment and selection of sedatives and paralytics is important. The appropriate selection and administration of medications renders the patient rapidly unconscious and flaccid in order to facilitate emergent endotracheal intubation and minimizes the risk of aspiration. Many studies debate the efficacy and outcomes of patients that undergo the procedure performed in the prehospital or inter-facility transfer setting. 

In the case of Drew, where a paralytic agent was used for intubation without sedation, he may have been fully aware of his environment, including pain, but unable to respond. In addition to this inhumane care, this circumstance allows for potentially adverse physiologic responses to airway manipulation, including tachycardia, hypertension and elevated intracranial pressure. The use of a sedative prevents or minimizes these physiologic effects and the patient is unaware of the procedure.

In some cases, providers can select an induction agent that both facilitates RSI and ameliorates the patient's underlying condition. For example, ketamine may be used as a dissociative sedative that allows the airway reflexes to remain intact and, in severe asthma patients, reduces bronchospasms. This type of induction agent may allow for the potentially difficult intubation patient to continue breathing and oxygenating without utilization of a paralytic agent potentially complicating the airway management should intubation become difficult or impossible.

Ethical aspect of paralysis during RSI
Paralysis and intubation is an extremely frightening experience for patients, so they must receive appropriate medication for sedation first. If not, they will be aware of everything happening around them while being unable to move or breathe. This procedure is deadly in the hands of the wrong provider, yet lifesaving in the hands of the proficient and skilled provider.

Paralysis with a neuromuscular blockade is a drastic measure with physical, psychological and social dangers. Many health care providers do not examine the ethical aspect of neuromuscular paralysis. When a patient is paralyzed, they lose their respiratory drive while being fully aware of their surroundings. In Drew's case, the endotracheal tube was place in his esophagus and he was not able to breathe on his own. To be fully conscious, hypoxic and paralyzed captures a modern vision of torture and helplessness.

In the event that a patient is rapidly crashing and an airway needs to be secured, it may be temporarily acceptable to push a paralytic, intubate and then immediately follow up with an amnestic agent. This should only be done in extreme cases where the establishment of an airway cannot be done and optimal paralysis is necessary. These patients are generally those who you cannot oxygenate or ventilate, which is the worst possible scenario when managing a patient's airway. 

Once a patient is intubated, the challenge is post-intubation management to prevent a number of issues, including patient self-extubation. Maintaining appropriate sedation and paralysis is a delicate balance and recognition of clinical indicators. These clinical indicators may be as simple as recognizing the slowly increasing heart rate, over breathing the ventilated rate, or recognition of the appearance of an alveolar cleft on the waveform capnography for the patient attempting to spontaneously breathe. 

While Drew's case is a tragic one, we can closely examine this case to learn important points about airway management. The process of appropriate sedation and paralysis for the initial process is just as important as the post-intubation management process. The procedure and skill of RSI can be lifesaving when appropriately applied or deadly in the hands of those who fail to recognize the importance of training and proficiency in application.

References
1. Walls RM, et.al: Manual of Emergency Airway Management. 2^nd Edition. Edited by Walls RM, Murphy MF. Philadelphia: Lippincott Williams and Wilkins; 2004:22

2. Weingart GS et al. Estimates of sedation in patients undergoing intubation in US EDs. 2013. Am J of EM.

3. Jordan B et al. Inadequate provision of postintubation anxiolysis and analgesia in the ED. 2008. Am J of EM

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