II. Approach: Emergency back-up plan

  1. See Emergency Decision Cycle (OODA Loop, AAADA Model)
  2. Clinician's responsibility to prepare with all necessary devices
    1. Check that they are operational before pushing induction agents and paralytics
  3. Levitan describes an emergency back-up parachute approach to intubation
    1. Every step in intubation should have a back-up plan (Boy Scout "Be Prepared" motto)
    2. Two ways to ventilate
    3. Two ways to oxygenate
    4. Two ways to intubate
  4. UMMC Shock-Trauma Advanced Airway Plan
    1. Intubation attempt with any technique
    2. Intubation attempt using Video Laryngoscope and Gum Elastic Bougie
    3. Intubation attempt by back-up provider (or attending physician)
    4. Attempt Supraglottic airway (e.g. Laryngeal Mask Airway)
    5. Surgical airway (Cricothyrotomy)
  5. Be prepared for Cricothyrotomy
    1. Have plan A and plan B (see above)
      1. Also have a "Go to Hell Plan" in case of "Can't Oxygenate, Can't Intubate"
    2. Palpate the neck for the cricothyroid membrane prior to each intubation
    3. Cricothyrotomy kit should be immediately available in case of complete airway obstruction
  6. Be prepared for failed definitive airway placement
    1. Have Extraglottic Device (e.g. Laryngeal Mask Airway or LMA) available (with practiced use)
  7. Have at least two methods of laryngeal exposure immediately available (with practiced use of each)
    1. Direct Laryngoscope
    2. Video Laryngoscope
  8. Have at least 2 Endotracheal Tubes available
    1. Estimated size for the patient's body habitus
    2. One Endotracheal Tube size smaller than expected
  9. Have two oxygen sources (not on splitter)
    1. Preoxygenation oxygen source (e.g. Non-Rebreather Mask with reservoir at 12 LPM)
    2. Apneic Oxygenation source (High Flow Nasal Cannula oxygen source at 15 LPM)
  10. Have two suction devices
    1. Open suction tubing without suction tip
    2. Yankauer suction (or preferably a better tip such as “S3,” “Big Stick,” or “Big Yank” )
      1. https://www.annemergmed.com/article/S0196-0644(16)30793-4/fulltext

III. Preparation: Mnemonic - SOAP-ME

  1. Suction
    1. Yankauer suction (or better alternative as above)
    2. Second suction tubing with no tip attached
  2. Oxygen
    1. High Flow Oxygen device (e.g. Non-Rebreather Mask with reservoir)
    2. Consider CPAP or BIPAP for preoxygenation
    3. Second oxygen source with Nasal Cannula (up to 15L/min) for Apneic Oxygenation
  3. Airway equipment
    1. Direct Laryngoscope
    2. Video Laryngoscope
    3. Elastic Bougie
    4. Endotracheal Tube
    5. Laryngeal Mask Airway (back-up plan)
  4. Patient Positioning
    1. Pull Mandible forward
    2. Sit patient up (at least 20 degrees) into ramped position (especially if obese)
      1. Reverse Trendelenburg if patient cannot be flexed at waist (e.g. Hip Fracture)
      2. Inclined torso improves oxygenation and glottis view, and decreases aspiration risk
      3. Khandelwal (2016) Anesth Analg 122(4): 1101-7 [PubMed]
    3. Ear to sternal notch
      1. http://www.emdocs.net/novel-tips-airway-management/
      2. Head parallel with ceiling
      3. Ear tragus at level of sternal notch
    4. Adjust overall bed height to align patient to clinician
      1. Patient's face should be at xiphoid of clinician for optimal intubation angle
  5. Monitoring Equipment
    1. Telemetry
    2. Oxygen Saturation
    3. Capnography (End-Tidal CO2)

IV. Preparation: Details

  1. Prepare for Rapid Sequence Intubation
    1. Indicated if not crash airway or awake intubation needed for difficult airway
  2. Monitoring Telemetry, Capnography and Pulse Oximetry (Hypoxemia, Bradycardia)
    1. Pretreatment with Atropine 0.02 mg/kg is no longer recommended
    2. Some pediatric providers have it ready at itubation in case of symptomatic Bradycardia (esp. age under 1 year)
  3. Check Laryngoscope for light and blade size (See above)
    1. Video Laryngoscopy is superior to Direct Laryngoscopy for successful first-pass intubation (by Odds Ratio >2)
      1. Video Laryngoscopy is also associated with reduced risk of esophageal intubation
      2. However, no difference in poor outcomes when compared with Direct Laryngoscopy
      3. De Jong (2014) Intensive Care Med 40(5): 629-39 [PubMed]
    2. Direct Laryngoscope (with working bulb and battery)
      1. When Video Laryngoscopy fails, Direct Laryngoscopy is the most common rescue device
  4. Suction (critical for all patients, especially for children)
    1. Two suction tubes are ideal (one Yankauer and one with tubing only to suction large particulate matter)
  5. Select ET size and length (See Endotracheal Tube)
    1. Cuffed ET Tubes may be used in infants and children
    2. Endotracheal Tube (including a size smaller than anticipated)
  6. Stylet should NOT extend beyond distal ET
    1. Glidescope intubation requires glidescope stylet with deep hockey-stick bend
  7. Elastic Bougie
    1. Curl into a tight loop if using a hyperangulated Laryngoscope Blade (e.g. Glidescope)
  8. Images
    1. lungAirwayStylets.png

V. Preparation: Additional specific measures to consider

  1. Consider Normal Saline 10-20 ml/kg (to 500 to 1000 ml) bolus prior to RSI (especially in children)
    1. Anticipate post-intubation Hypotension (related to sedation, PPV, PEEP)
      1. Monitor Blood Pressure frequently in the period around intubation
      2. Post-intubation Hypotension is associated with worse outcomes
      3. Hypotension occurs in up to 25% of emergency intubations (Cardiac Arrest in 3% of intubations)
    2. Hypotension following RSI and intubation may be predictable and may be prevented with bolus
      1. Children
      2. Age over 65 years old
      3. Septic Shock
      4. Borderline MAP (65-70 mmHg) pre-intubation
      5. Shock Index (HR/SBP) > 0.8
    3. References
      1. Mallemat in Herbert (2017) EM:Rap 17(2): 4-5
  2. Decompress Bowel Obstruction with Orogastric Tube prior to intubation
    1. Vomiting otherwise may be profuse and result in significant aspiration andvery difficult intubation

VI. Resources

  1. Airway Cam (Levitan)
    1. http://www.airwaycam.com/

VII. References

  1. Levitan (2013) Practical Airway Management Course, Baltimore
  2. Weingart et al in Herbert (2016) EM:Rap 16(11): 4-5

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