Today I review and link to First10EM Resuscitation Plans For Airway Management (Including Rapid Sequece Intubation):
Airway
Note to myself: It is critical to review each of these five posts completely.
- Airway part 1: Optimizing the basics
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Case
A 55 year old man was found unconscious in the bathroom by his family. He has a GCS of 7. His vital signs are a heart rate of 130, a blood pressure of 90/55, a respiratory rate of 28, and an oxygen saturation of 89% on room air. He is lying flat on the resuscitation stretcher and making some sonorous breath sounds. You resident grabs a laryngoscope and says, “ABCs… let’s get this guy intubated”…
My approach
Although many airway talks start at intubation, immediate intubation is rarely the first step in resuscitation. Basic airway maneuvers are essential. Many patients can be managed with simple maneuvers alone, preventing what seems like an otherwise necessary endotracheal tube. Even when the tube is ultimately necessary, starting with basic airway maneuvers stabilizes the patient, and gives you time to resuscitate, gather information, and effectively pre-oxygenate.
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- Airway part 2: Is the patient ready?
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Case
A 55 year old man was found unconscious in the bathroom by his family. He has a GCS of 7. His vital signs on arrival are a heart rate of 130, a blood pressure of 90/55, a respiratory rate of 28, and an oxygen saturation of 89% on room air. Although he was originally making sonorous noises, after elevating the head of the bed to 30 degrees, inserting a nasopharyngeal airway, and applying a jaw thrust, he is breathing quietly at 23 breaths a minutes, and his oxygen saturation has climbed to 92% with facemask oxygen. Is it time for intubation?
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My approach
Many airway discussions start from the moment that a laryngoscope is pulled out. In emergency medicine and critical care, we are rarely managing an airway in isolation. We manage the airway in the context of a critically ill patient. Therefore, it is essential to consider the physiology of the patient when deciding on the most appropriate time for advanced airway interventions like intubation.
For a number of reasons, the peri-intubation period is a time of high risk for cardiovascular collapse. Occasionally, rapidly evolving airway obstruction mandates immediate intervention. However, for the vast majority of critically ill patients, rushing to an advanced airway increases risk. When intubating critically ill patients, there are 5 major risk factors for cardiovascular collapse that must be considered: hypoxemia, hypotension, severe metabolic acidosis, right ventricular failure, and severe bronchospasm. (Mosier 2015)
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- Airway part 3: Intubation
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Case
A 55 year old man was found unconscious in the bathroom by his family. He has a GCS of 7. His vital signs on arrival are a heart rate of 130, a blood pressure of 90/55, a respiratory rate of 28, and an oxygen saturation of 89% on room air. After using basic airway maneuvers to temporarily stabilize his airway, you were able to take the time to appropriately resuscitate and pre-oxygenate him. His vital signs are now a heart rate of 105, a blood pressure of 122/77, a respiratory rate of 16, and an oxygen saturation of 100% with a non-rebreather set at flush rate and nasal prongs at 15 L/min. However, he remains unconscious and you think it is now time to proceed with intubation…
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My approach
As was discussed in the last post, before starting with RSI it is important to consider if the patient is physiologically ready for intubation. After appropriate resuscitation and pre-oxygenation, we can start with the procedure of intubation.
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- Airway part 4: Cricothyroidotomy
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Case
A 55 year old man was found unconscious in the bathroom by his family. After appropriate resuscitation and pre-oxygenation, you determine that there are no major predictors of difficulty, and so proceed with RSI. On 2 attempts at laryngoscopy, both direct and video, you cannot visualize the cords. The LMA won’t sit properly, and now his oxygen saturation is 70% despite your best attempt at bag valve mask ventilation…
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My approach
In the can’t intubate, can’t oxygenate scenario, I recommend a surgical approach to cricothyroidotomy. In the NAP4 audit, 60% of needle cricothyroidotomy attempts failed. In contrast, 100% of surgical cricothyroidotomy attempts were successful. (Cook 2011; Nolan 2011) Although there are a few studies indicating that guidewire techniques are equally fast to surgical techniques, such studies are not consistent. More importantly, such studies can never reproduce the stress and adrenaline of real can’t intubate can’t oxygenate scenarios. I simply cannot imagine trying to thread a guidewire in that situation. Furthermore, there are numerous significant complications reported with jet ventilation through a catheter. (Duggan 2016) The Difficult Airway Society guidelines recommend surgical front of neck access over catheter based approaches. Specifically, they recommend the scalpel-bougie technique described below. (Pracy 2016; Frerk 2015)
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Required equipment:
- Scalpel (a broad blade with the same width as the tracheal tube, such as a number 10 blade, is ideal)
- Bougie
- Endotracheal tube, cuffed, size 6.0mm (Frerk 2015)
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- Part 5: Post intubation care
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Case
A 55-year-old man was found unconscious in the bathroom by his family. He has a GCS of 7. His vital signs on arrival are a heart rate of 130, a blood pressure of 90/55, a respiratory rate of 28, and an oxygen saturation of 89% on room air. After using basic airway maneuvers to temporarily stabilize his airway, you were able to take the time to appropriately resuscitate and pre-oxygenate him, prior to proceeding with intubation. You pass the tube easily on the first attempt. Looking around the room for someone to high-five, you realize your team is waiting for your instructions for the ongoing care of this sick patient…
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My approach
Confirm ETT placement and secure the tube
Confirming tube placement is, in my mind, an essential step of the intubation procedure itself, but is important enough to be repeated here. Confirm placement with quantitative end-tidal capnography, and then leave the waveform capnography in place for monitoring purposes. (Apfelbaum 2013; Frerk 2015) Take a moment to secure the tube, so your hard work is not undone. (I have always left the method of securing the tube to our excellent RTs. I am not aware of any evidence that any one technique of securing the endotracheal tube is better than others, but would love to hear about studies if they exist. It makes sense to use the same technique favoured by your ICU, to avoid the unnecessary risk of changing devices later.)
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Continue Resuscitation
In the emergency department we intubate critically ill patients. The plastic tubing of the endotracheal tube is very rarely the definitive treatment required. In fact, the transition to positive pressure ventilation is often detrimental to the patient’s hemodynamics. The procedure of intubation requires focus, which can result in a loss of awareness of the patient’s overall status. Ideally, critically ill patients are managed by multiple physicians, allowing one to focus on the airway while another leads the overall resuscitation. (Brindley 2017) However, this simply is not feasible in some clinical environments. My first step after confirming endotracheal tube placement is to ensure I have adequate situational awareness, repeat a primary survey, get a repeat set of vital signs, and address any immediate life-threats.
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