by reuben in airway
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Rapid sequence intubation, the simultaneous administration of a paralytic and induction agent immediately followed by laryngoscopy, provides the optimal view of the glottis and prevents emesis. RSI is the best strategy for most patients who require intubation, but not all. When you’ve decided to intubate, first maximally preoxygenate. If the patient will not cooperate with your preoxygenation plan, even after you’ve asked nicely, that’s your cue to add cooperation in a vial, ketamine, and then oxygenate, before you push the paralytic and intubate. This is delayed sequence intubation. Otherwise, carry on with preoxygenation, and consider a couple of special situations. The first is the patient who is about to arrest–obtunded, no blood pressure. Any induction agent will cause sympatholysis which, along with the transition to positive pressure ventilation, may precipitate arrest, so ideally we would avoid both while the patient is in the state of nearly arrested. Resuscitate aggressively with fluids, vasoactive drips and treatment of the underlying problem for as long as you can before intubating. If you must intubate the patient who is obtunded with no blood pressure, the safest way to do it is often without any drugs at all, while the patient continues to breathe. If you have to give meds, dose sedatives low and paralytics high. The next special situation is the patient who has a severe oxygenation or ventilation deficit. The severe oxygenation deficit patient saturates less than 90% on 100% NIV; the severe ventilation deficit patient is compensating for a severe metabolic acidosis, e.g. DKA with pH 6.7….
Awake intubation is placing an endotracheal tube in the trachea while the patient continues to breathe. The principle advantage over RSI is that you do not take away the patient’s respirations or airway reflexes, which makes the process safer in many circumstances. The disadvantages are that the patient’s personality and movements, as well as the patient’s airway reflexes, must be managed, which takes time, and even when done well, the view you get won’t be as good as in a paralyzed patient. Instrumenting the back of the throat may cause gagging and possibly vomiting, though this is quite unlikely to lead to clinically significant aspiration (because the patient is awake). The more difficult airway features, and the less urgent the intubation, the more likely you should intubate awake. Patients who are at high risk to vomit are not good candidates for an awake technique. The two arms of awake intubation are local anesthesia and systemic sedation. The more cooperative your patient, the more you can rely on local; perfectly cooperative patients can be intubated awake without any sedation at all. More commonly in the ED, patients will require sedation. Ketamine is the agent of choice in most circumstances, as it sedates without depressing respiration or airway reflexes. In somewhat cooperative patients, 20 mg boluses, titrated to effect, work very well. In very uncooperative/agitated patients, a full dissociative dose (1.5 mg/kg) is an effective strategy though a brief period of apnea is usual if dissociative doses are delivered as a bolus, and laryngospasm is a possible complication….
by reuben in airway
There was a period in the history of emergency medicine when cricothyrotomy was the primary airway management strategy for all patients in cervical spine precautions. We have since learned that most of these patients can be intubated orally, but in the intervening years have lost our nerve when it comes to using the neck for airway access. Today, everyone agrees that the most important error around emergency cricothyrotomy is that it is performed too late [1, 2, 3]. An unsuccessful cricothyrotomy performed at the right time is defensible; a successful cricothyrotomy performed too late is indefensible. Both lead to terrible outcomes: one is good, defensible care, the other is poor, indefensible care. The pivotal element in emergency surgical airway decision-making is giving yourself permission to initiate the procedure before the patient is dead. The Cricothyrotomy Menu There are a variety of strategies for accessing the trachea via the neck and the terminology is confusing. Open cricothyrotomy, often referred to as surgical cricothyrotomy, is using a knife to cut a hole in the cricothyroid membrane and placing a tracheostomy tube or endotracheal through that hole. Several techniques have been described, including the no-drop technique, the rapid four-step technique, and the scalpel-bougie technique. Percutaneous cricothyrotomy is a term usually used in distinction to surgical or open cricothyrotomy, implying a less invasive approach. Percutaneous cricothyrotomy facilitates the placement of a tracheostomy or endotracheal tube in the trachea by using either a Seldinger tube-over-dilator-over-wire technique, or a tube-over-trocar device [1, 2]. Most emergency physicians are referring to the…
The double setup is an airway management strategy conventionally carried out in the operating room, in a stable or relatively stable patient who requires a definitive airway but is anticipated to be very difficult to intubate orally. An otolaryngologist or other surgeon fully prepares to perform a cricothyrotomy or tracheotomy–patient prepped, all equipment laid out, sterile gown and gloved, scalpel in hand–and then gives the anesthesiologist the nod, at which point the patient is induced and orotracheal intubation is attempted. If unsuccessful, anesthesia nods to surgery, who proceeds with a neck incision. Emergency physicians are trained to manage difficult oral airways and perform cricothyrotomy–how does the double setup apply to our environment? Once the decision to intubate has been made and preoxygenation has been initiated (don’t forget the nasal cannula), ask two questions: How urgently must this patient be intubated? How difficult do I predict this airway to be? Scenario 1: Must intubate immediately, very scary airway. Some patients need to be intubated right now, and some patients who need to be intubated right now also are predicted to have difficult airways. The paradigmatic examples of this stressful situation are the dynamic airway insults: patients with bullets, bites or burns (neck trauma, anaphylaxis, airway burn or caustic exposure) who are already showing signs of airway embarrassment. The proper mentality in these cases is this patient is going to require cricothyrotomy, but I’m going to attempt orotracheal intubation, just to make sure. There is no time for a fancy airway assessment or fancy preparations,…
vector image for screen viewing acrobat document for printing Changes in v13: nasal cannula and preoxygenation sections beefed up added airway management strategy section removed incremental FiO2/PEEP chart roc dose changed from TBW to IBW added section on cricothyrotomy technique ultrasound added to post-intubation complications assessment added proviso, “pretreatment agents are always optional.” added S to DOPES mnemonic (breath stacking) added “function” to “verify cuff” for ETT changed phenylephrine from post to peri intubation hypotension fancy style enhancements Bonus: personnel arrangement diagram
by reuben in airway
Those of you who have adopted the strategy of Nasal Oxygen During Efforts at Securing A Tube know how powerful this technique is, and know that there is no reason not to take advantage of apneic oxygenation by applying nasal cannula oxygen during every airway management case. After observing the effect of this technique a few times, you may have shaken your head at all the unnecessary catecholamines released by you and your patients over the years as you or your trainee hunted around for cords as the saturation fell. But there’s also a small part of you that is glad to have been part of this earlier era, when intubating in the emergency department was a harrowing combination of skill, brute force, and luck. When intubating in the emergency department left providers drenched in sweat and epinephrine, hands trembling, wired and exhausted. When intubating in the emergency department felt like saving a life. These days, with all the fancy airway tools and techniques, placing an endotracheal tube in the trachea often feels as dramatic as placing a foley in the urethra. Your hard-fought airway skills and intestinal fortitude seem wasted. You might find yourself obscuring your intern’s view by “applying cricoid pressure” just to watch him get that same panic-induced nausea you had to suffer day in day out, all those years, glidescope be damned. Intubation these days is too friggen easy. Well it’s about to get even easier. The high flow nasal cannula is a device that has been used by neonatologists for some…