Knowing when to intubate versus when to not intubate

[deleted1139416]

This is a very frustrating question on UWORLD. I understand that in some circumstances, such as anaphylaxis or croup, you would use epinephrine and racemic epi, respectively, over intubation. But for something like opioid intoxication, UWORLD sometimes says that intubation is the right first choice and sometimes naloxone is the right first choice. So should I assume that if there is a fast way to reverse respiratory depression, I wouldn't choose intubation? For example, if someone has a RR of 4 due to benzo overdose, would flumazenil be the right choice over intubation if they were both answer choices?

---

Members don't see this ad.

 

[Dr. Basketball]

Flumazenil use in the ER in a benzo overdose is controversial because it can trigger a seizure if the patient is a long time user of either benzos or alcohol.(We did a simulation and our pt. had OD'd on benzos and we gave flumazenil, that is the only reason I know that.)

Here are the indications for intubations according to Uptodate:

In emergency medicine, the most common indications for tracheal intubation are acute respiratory failure, inadequate oxygenation or ventilation, and airway protection in a patient with depressed mental status.

When I was doing questions, I remember a lot of times when the right answer was to intubate, it was because the GCS was low.

Maybe someone else can explain this better than I can. Hope this helps!

 

[TooMuchResearch]

This is a very frustrating question on UWORLD. I understand that in some circumstances, such as anaphylaxis or croup, you would use epinephrine and racemic epi, respectively, over intubation. But for something like opioid intoxication, UWORLD sometimes says that intubation is the right first choice and sometimes naloxone is the right first choice. So should I assume that if there is a fast way to reverse respiratory depression, I wouldn't choose intubation? For example, if someone has a RR of 4 due to benzo overdose, would flumazenil be the right choice over intubation if they were both answer choices?

Don't intubate opioid overdoses before massive narcan doses.

Do you have any specific examples that I can try to provide a more nuanced take?

 

[esob]

GCS 8 = intubate. The exception on NBME is usually if the person is found down with no info, AND Naloxone is an option. The only other weird NBME scenarios that I remember are burns. If you suspect someone is undoubtedly going to lose their airway from impending edema, intubate.