What are the recommendations for intubating unresponsive patients without medication, such as sedatives (e.g. etomidate) and paralytics (e.g. rocuronium)?

Recommendations for Intubating Unresponsive Patients Without Medication

Intubating unresponsive patients without medication (no sedatives or paralytics) is generally not recommended due to significantly higher risks of aspiration, airway trauma, and mortality compared to rapid sequence intubation (RSI) with appropriate medications. 1

Rationale for Using Medications Even in Unresponsive Patients

Risks of Intubation Without Medications

• A prospective study comparing intubation with and without paralysis found that non-paralyzed patients experienced:
  • 15% aspiration rate
  • 28% airway trauma rate
  • 3% mortality directly related to intubation
  • None of these complications occurred in the RSI group 1

Protective Reflexes May Still Be Present

• Even in unresponsive patients, protective airway reflexes may remain intact
• Without medications, these reflexes can lead to:
  • Coughing and gagging during intubation attempts
  • Increased risk of aspiration
  • Difficult intubation conditions
  • Increased intracranial pressure

Recommended Approach for Unresponsive Patients

Assessment of Unresponsiveness

• Verify true unresponsiveness (Glasgow Coma Scale, response to painful stimuli)
• Determine cause of unresponsiveness (may influence medication choices)
• Assess for difficult airway markers

Medication Recommendations

1. Use RSI medications even in unresponsive patients

   • Sedative agent (adjusted dose based on hemodynamic status)
   • Neuromuscular blocking agent

2. Sedative options (reduced dosing may be appropriate):

   • Etomidate: 0.2-0.3 mg/kg IV (hemodynamically neutral) 2
   • Ketamine: 1-2 mg/kg IV (preferred in shock states) 2
   • Propofol: Reduced dose if using in unresponsive patients (caution with hypotension) 2

3. Neuromuscular blocking agents:

   • Succinylcholine: 1-1.5 mg/kg IV (first-line unless contraindicated) 2
   • Rocuronium: 0.9-1.2 mg/kg IV (when succinylcholine contraindicated) 2, 3

Special Considerations

• Septic patients: Consider avoiding etomidate due to concerns about adrenal suppression 3
• Hemodynamically unstable patients: Consider ketamine as the preferred sedative 3
• Pediatric patients: The American College of Critical Care Medicine recommends using sedative-hypnotic agents that permit rapid sequence induction (etomidate, ketamine, propofol) depending on medical history and clinical situation 3

Important Caveats and Pitfalls

Risk of Awareness During Paralysis

• A significant concern is that patients may receive paralytic agents without adequate sedation
• One study found that 63.1% of pediatric patients received additional sedation more than 15 minutes after etomidate administration, potentially experiencing paralysis without sedation 4
• Always ensure ongoing sedation after initial RSI medications wear off

Hemodynamic Considerations

• Have vasopressors readily available to manage potential hypotension
• Consider reduced dosing of sedatives in hemodynamically unstable patients
• Monitor blood pressure closely during and after intubation

Post-Intubation Management

• Confirm tube placement with multiple methods
• Initiate appropriate sedation/analgesia immediately after intubation
• Minimize sedation in mechanically ventilated septic patients when appropriate, targeting specific titration endpoints 3

Conclusion

While it may seem intuitive to skip medications in an already unresponsive patient, the evidence strongly suggests that proper RSI with appropriate medications significantly reduces complications and improves outcomes. The risks of intubating without medications (aspiration, trauma, mortality) far outweigh the perceived benefits of avoiding medication administration in these vulnerable patients.