On March 23, I discussed two outstanding videos by Dr. Scott Weingart on awake intubation. Today I will discuss some additional details from those videos. But you need to watch both videos.
The first video (1) was produced about 3 years ago and is approximately 30 minutes long and is summarized in the March 23 post. (2) The shorter video (3) is about 8 minutes long and was produced by Dr. Weingart about two years ago. The second video shows two actual awake intubations from start to finish.
An awake intubation consists of ten steps: (1) Dry Out the Mucosa, (2) Suction and Dry the Mucosa, (3) Provide Mucosal Anesthesia with Aerosolized Lidocaine, (4) Give Viscous Lidocaine, (5) Transtracheal Injection (not recommended), (6) Instead, Transtracheal Trickle (Dr. Weingart’s term, (7) Preoxygenate, (8) Sedate, (9) Use Video Larygnoscope (if available) to pass brougie and endotracheal tube, (10) Postentubation management.
All the above steps are discussed in the March 23 post. (2)
Additional details on Step 6, the “Transtracheal Trickle”:
Instead of using an a 14 to 16 gauge angiocath attatched to a syringe to very slowly trickle the lidocaine into the back of the throat as described in the lecture video, you can use the Mucosal Atomization Device attatched to a syringe. The MAD generates a fine mist and it can numb the epiglottis and top of the cords. By placing the video laryngoscope in the mouth, you can visualize the trachea, pass the MAD tip through the vocal cords and anesthetize the trachea. See the Awake Intubation Demonstrations (3) Information on the Mucosal Atomization Device is available online. (4)
Additional details on Step 8, Sedation:
For sedation, Dr. Weingart recommends: Versed 2 to 4 mg which takes three to five minutes to take effect; or Ketamine and Propofol in the same syringe; or Ketamine alone; or dexmedetomidine (Precedex).
Dr. Weingart cautions against using fentanyl with Versed because together they make people stop breathing which defeats the purpose of doing an awake intubation.
For the same reason avoid propofol alone—it makes the patient stop breathing.
He states that he usually doesn’t use Versed. He might use 2 mg of Versed for its amnestic effects if he is sure that the patient is fully topically anesthetized.
He states “my favorite sedative is a combination of ketamine and propofol. I use a 75% ketamine 25% propofol mixture”. Take 75 mg of ketamine in 7.5 cc and 25 mg of propofol in 2.5 cc and put them in the same syringe.
Then you push the mixture one cc at a time. Push one cc and wait a minute or so. Push one cc and wait a minute or so. You do this until you get them to the level of sedation that you want.
Note that if you are using ketamine alone in the syringe, you also push one cc at a time and wait a minute, etc.
It is also a good idea to restrain the patient if they might be grabber and pull the tube out.
One final tip, positioning the patient is the key to a successful intubation. The auditory meatus needs to be aligned with the sternal notch.
(1)Awake Intubation Lecture, Dr. Scott Weingart available at
https://vimeo.com/2546522
(2) How to Do An Awake Intubation—Two Outstanding Videos available at
https://www.tomwademd.net/2012/03/23/an-outstanding-video-on-how-to-do-an-awake-intubation/
(3) Awake Intubation Demonstrations, Dr. Scott Weingart available at
https://emcrit.org/misc/awake-intub-video/
(4) Mucosal Atomization Device from Wolfe Tory Medical available at https://www.wolfetory.com/Products/MAD/
