need help on dumb question..vocal cord paralysis during intubation

[ketap]

hi, i am very sorry if this is a real dumb question..but i just can't find enough sources to find this answer : i intubated a patient yesterday, i gave her a midazolam (1mg/kg) 5 mg bolus and titrated it approximately 2 minutes later another 2 mg bolus...and i gave her also 2 amp 40mg lidocaine 2% 3 minutes before intubation...now, this might be a very dumb question: the patient was sedated enough IMHO and there was no sign of increased sympathetic response to intubation (satO2, heart rate, blood pressure was all fine) ...but i saw that the patient's vocal cord was still moving...why ? is it because i choose the midazolam over propofol or is it because i gave her too little lido? or is it because of no muscle relaxant being used?
sorry if this is very dumb too you...

please help me to improve myself....thx u so much
regards,Ketap

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[sevoflurane]

hi, i am very sorry if this is a real dumb question..but i just can't find enough sources to find this answer : i intubated a patient yesterday, i gave her a midazolam (1mg/kg) 5 mg bolus and titrated it approximately 2 minutes later another 2 mg bolus...and i gave her also 2 amp 40mg lidocaine 2% 3 minutes before intubation...now, this might be a very dumb question: the patient was sedated enough IMHO and there was no sign of increased sympathetic response to intubation (satO2, heart rate, blood pressure was all fine) ...but i saw that the patient's vocal cord was still moving...why ? is it because i choose the midazolam over propofol or is it because i gave her too little lido? or is it because of no muscle relaxant being used?
sorry if this is very dumb too you...

please help me to improve myself....thx u so much
regards,Ketap

No paralytic.

 

[Idiopathic]

i expected something more dramatic based on the title.

 

[RxBoy]

hi, i intubated a patient yesterday, i gave her a midazolam (1mg/kg) 5 mg bolus and titrated it approximately 2 minutes later another 2 mg bolus...and i gave her also 2 amp 40mg lidocaine 2% 3 minutes before intubation

no sign of increased sympathetic response to intubation (satO2, heart rate, blood pressure was all fine)

You induced a pt with 7 mg versed, 40 mg lidocaine, I've given close to that for pre procedural anxiolysis.

Benzos rarely cause apnea. If you threw in some fentanyl or propofol, you would of probably got apnea or as you refer to it "vocal cord paralysis".

I highly doubt there was no sympathetic discharge. Pts bp was probably 200s/100s with HR in the 130s. Unless of course this was a ICU/code intubation. With a straight benzo induction, completely plausible.

 

[Mman]

You induced a pt with 7 mg versed, 40 mg lidocaine, I've given close to that for pre procedural anxiolysis.

Benzos rarely cause apnea. If you threw in some fentanyl or propofol, you would of probably got apnea or as you refer to it "vocal cord paralysis".

I highly doubt there was no sympathetic discharge. Pts bp was probably 200s/100s with HR in the 130s. Unless of course this was a ICU/code intubation. With a straight benzo induction, completely plausible.

Given the question, you know it wasn't an intubation in the OR.

 

[Mac4]

Given the question, you know it wasn't an intubation in the OR.

You never know. The OP "titrated" midazelam and waited three minutes after lidocaine to intubate. It was probably not an emergent intubation outside the OR.

 

[Mman]

You never know. The OP "titrated" midazelam and waited three minutes after lidocaine to intubate. It was probably not an emergent intubation outside the OR.

Nobody in an OR is taking their sweet time working in some versed and lidocaine and then intubating with no other induction agent or paralytic. Or at least nobody that is asking why the vocal cords were still moving.

 

[ASA6]

Nobody in an OR is taking their sweet time working in some versed and lidocaine and then intubating with no other induction agent or paralytic. Or at least nobody that is asking why the vocal cords were still moving.

The whole thing is suspect. Its clearly not in the OR, because if the OP is an anesthesia resident, at this level, the attending would be present. If its on the floor, again, not a ca-1 (at this time of the year anyways), and if its a ca-2 or 3, they would know better. So its either an ICU fellow (which i hope would still know better)/medicine resident in the ICU, or we are being trolled.

 

[ASA6]

Nobody in an OR is taking their sweet time working in some versed and lidocaine and then intubating with no other induction agent or paralytic. Or at least nobody that is asking why the vocal cords were still moving.

this post explains it, this guy is a GP that practices in a rural ER, so likely non emergent intubation in the ER:

Ketafol20: well, i am basically a general physician, so i have no anesthesia training besides when i was having my internship and of course , i still have lack of airway management practice , but i am very interested in airway management ( so i read quiet many books, but quiet lack of practice though) as i am having interest to anesthesiology also..

 

[imfrankie]

You induced a pt with 7 mg versed, 40 mg lidocaine, I've given close to that for pre procedural anxiolysis.

Benzos rarely cause apnea. If you threw in some fentanyl or propofol, you would of probably got apnea or as you refer to it "vocal cord paralysis".

I highly doubt there was no sympathetic discharge. Pts bp was probably 200s/100s with HR in the 130s. Unless of course this was a ICU/code intubation. With a straight benzo induction, completely plausible.

Don't think the poster meant apnea when (s)he said "vocal cord paralysis"

 

[Sergio99]

You already got the answer to your question with the posts above. I am surprised you were able to intubate with that amount of sedation, unless you patient was very debilitated.

Now, if, as the previous quote says, you are a GP with an interest in anesthesia, you will be very wise if you do an anesthesia residency, the earlier the better, both for your own good and for everybody else's good. I greatly advise you to start looking for anesthesia programs and applying. If you like physiology, pharmacology and airway management, anesthesia is a wonderful specialty. You will not regret it.

 

[ketap]

hello, first of all i am sorry if i didn't mentioned earlier that i am not an anesthesiologist..yes i am still a GP and i am practising in rural area ,not in the united states though...and i am sorry not giving details about this case..that is because i wanted to concentrate only on this subject (i.e.the vocal cord is still moving ---yeah,she was still breathing at that time)

i have read those answers and i really appreciate it..those answers help me very much..it was actually outside the OR, an emergency intubation in the ER but no signs of difficult ventilation or intubation.the patient has GCS 8-9, responded only to pain but showed sign of paradoxical breathing..so, i gave her versed (wait until time to peak effect reached ) to prevent decreased BP and because i still thought that she was not relax enough, and i didn't see any sign of diffult to ventilate ,so i decided to gave her another 2 mg versed, wait the onset again while waiting lidocaine to work..

i used versed because i didn't have the propofol nearby...i only had versed that time ,so i used it with lidocaine ..i have never intubate with only versed before (i know that it can be done even though it lacks of hypnotics effect and not suggested as a sole drug used for intubation)..and i didn't use RSI because i can't find relaxant nearby either..i know this sounds crazy to you, but that is the fact i had in my area..i have asked for those drugs so they are more reachable but no respond until now...

so, i use lidocaine spray before i put the tracheal tube to the trachea( yes the vocal cords are still moving) ,and then wait for a while..approximately 1 mnt and i put it in while the vocal cord abduct...

sorry if all of you feel annoyed by this dumb question, i didn't meant anyhting but to gain knowledge even the dumbest question from all of you and that is why i get to this forum, i still need lots to learned and following this forum and asking questions to all of you will surely make me better...

Sergio: regarding the residency program..well i am trying to reach it,]i haven't got the chance for it .i know it might be ridiculous but i am learning for step 1..i know i am not qualified to it yet but i am trying to improve myself

thx u very much for the responds, friends...

btw, imfrankie: i am sorry, i don't understand ..

Don't think the poster meant apnea when (s)he said "vocal cord paralysis"

i don't understand..when the patient is in apnea, won't the vocal cord stop moving?

please do bare with me..thx u

 

[dhb]

You did fine with the resources you had available

 

[Gern Blansten]

You did fine with the resources you had available

+1
I have seen much worse by people who should have known better.

 

[Sergio99]

...i am learning for step 1..i know i am not qualified to it yet but i am trying to improve myself...

You are doing a very good job at improving yourself. Any residency director would be delighted to have you in his program. Don't give up!

 

[ketap]

thank you for the supports,Friends ..i really appreciate it..it courages me more to reach the dream : becoming an anesthesiologist (hopefully i can be a great one )..
thx again and God Bless all of you..

regards, Ketap

 

[Idiopathic]

i don't understand..when the patient is in apnea, won't the vocal cord stop moving?

sometimes, but the muscles in that region, including those of the pharynx and larynx can have involuntary movements, especially when stimulated, and also remember the opposing effects of the vocal cord muscles (posterior cricoarytenoid and cricoythroid).

 

[ketap]

sometimes, but the muscles in that region, including those of the pharynx and larynx can have involuntary movements, especially when stimulated, and also remember the opposing effects of the vocal cord muscles (posterior cricoarytenoid and cricoythroid)

is it the same involuntary movement that responsible for laryngospasm?.. thx u