II. Approach: Emergency back-up plan
- See Emergency Decision Cycle (OODA Loop, AAADA Model)
- Clinician's responsibility to prepare with all necessary devices
- Check that they are operational before pushing induction agents and paralytics
- Levitan describes an emergency back-up parachute approach to intubation
- Every step in intubation should have a back-up plan (Boy Scout "Be Prepared" motto)
- Two ways to ventilate
- Two ways to oxygenate
- Two ways to intubate
- UMMC Shock-Trauma Advanced Airway Plan
- Intubation attempt with any technique
- Intubation attempt using Video Laryngoscope and Gum Elastic Bougie
- Intubation attempt by back-up provider (or attending physician)
- Attempt Supraglottic Airway (e.g. Laryngeal Mask Airway)
- Surgical airway (Cricothyrotomy)
- Be prepared for Cricothyrotomy
- Have plan A and plan B (see above)
- Also have a "Go to Hell Plan" in case of "Can't Oxygenate, Can't Intubate"
- Palpate the neck for the cricothyroid membrane prior to each intubation
- Cricothyrotomy kit should be immediately available in case of complete airway obstruction
- Have plan A and plan B (see above)
- Be prepared for failed definitive airway placement
- Have Extraglottic Device (e.g. Laryngeal Mask Airway or LMA) available (with practiced use)
- Have at least two methods of laryngeal exposure immediately available (with practiced use of each)
- Have at least 2 Endotracheal Tubes available
- Estimated size for the patient's body habitus
- One Endotracheal Tube size smaller than expected
- Have two oxygen sources (not on splitter)
- Preoxygenation oxygen source (e.g. Non-Rebreather Mask with reservoir at 12 LPM)
- Apneic Oxygenation source (High Flow Nasal Cannula oxygen source at 15 LPM)
- Have two suction devices
- Open suction tubing without suction tip
- Yankauer suction (or preferably a better tip such as “S3,” “Big Stick,” or “Big Yank” )
III. Preparation: Mnemonic - SOAP-ME
- Suction
- Yankauer suction (or better alternative as above)
- Second suction tubing with no tip attached
- Oxygen
- High Flow Oxygen device (e.g. Non-Rebreather Mask with reservoir)
- Consider CPAP or BIPAP for preoxygenation
- Second oxygen source with Nasal Cannula (up to 15L/min) for Apneic Oxygenation
- Airway equipment
- Patient Positioning
- Pull Mandible forward
- Sit patient up (at least 20 degrees) into ramped position (especially if obese)
- Reverse Trendelenburg if patient cannot be flexed at waist (e.g. Hip Fracture)
- Inclined torso improves oxygenation and glottis view, and decreases aspiration risk
- Khandelwal (2016) Anesth Analg 122(4): 1101-7 [PubMed]
- Ear to sternal notch
- http://www.emdocs.net/novel-tips-airway-management/
- Head parallel with ceiling
- Ear tragus at level of sternal notch
- Adjust overall bed height to align patient to clinician
- Patient's face should be at xiphoid of clinician for optimal intubation angle
- Monitoring Equipment
- Telemetry
- Oxygen Saturation
- Capnography (End-Tidal CO2)
IV. Preparation: Details
- Prepare for Rapid Sequence Intubation
- Indicated if not crash airway or awake intubation needed for difficult airway
- Monitoring Telemetry, Capnography and Pulse Oximetry (Hypoxemia, Bradycardia)
- Pretreatment with Atropine 0.02 mg/kg is no longer recommended
- Some pediatric providers have it ready at itubation in case of Symptomatic Bradycardia (esp. age under 1 year)
- Check Laryngoscope for light and blade size (See above)
- Video Laryngoscopy is superior to Direct Laryngoscopy for successful first-pass intubation (by Odds Ratio >2)
- Video Laryngoscopy is also associated with reduced risk of esophageal intubation
- However, no difference in poor outcomes when compared with Direct Laryngoscopy
- De Jong (2014) Intensive Care Med 40(5): 629-39 [PubMed]
- Direct Laryngoscope (with working bulb and battery)
- When Video Laryngoscopy fails, Direct Laryngoscopy is the most common rescue device
- Video Laryngoscopy is superior to Direct Laryngoscopy for successful first-pass intubation (by Odds Ratio >2)
- Suction (critical for all patients, especially for children)
- Two suction tubes are ideal (one Yankauer and one with tubing only to suction large particulate matter)
- Select ET size and length (See Endotracheal Tube)
- Cuffed ET Tubes may be used in infants and children
- Endotracheal Tube (including a size smaller than anticipated)
- Stylet should NOT extend beyond distal ET
- Glidescope intubation requires glidescope stylet with deep hockey-stick bend
-
Elastic Bougie
- Curl into a tight loop if using a hyperangulated Laryngoscope Blade (e.g. Glidescope)
- Images
V. Prevention: Post-Intubation Hypotension
- Anticipate post-intubation Hypotension (related to sedation, Positive Pressure Ventilation, PEEP)
- Monitor Blood Pressure frequently in the period around intubation
- Post-intubation Hypotension is associated with worse outcomes
- Hypotension occurs in up to 25% of emergency intubations (Cardiac Arrest in 3% of intubations)
-
Hypotension following RSI and intubation may be predictable and may be prevented with bolus
- Children
- Age over 65 years old
- Septic Shock
- Borderline MAP (65-70 mmHg) pre-intubation
- Shock Index (HR/SBP) > 0.8
- Management
- Consider Normal Saline 10-20 ml/kg (to 500 to 1000 ml) bolus prior to RSI (especially in children)
- Choose induction agents with less risk of Hypotension (Etomidate, Ketamine)
- Optimize mean arterial pressure >80-85 mmHg prior to intubation (fluids, Vasopressors)
- Consider Delayed Sequence Intubation
- Gradual titration of Ketamine while optimizing oxygenation and mean arterial pressure
- References
- Mallemat in Herbert (2017) EM:Rap 17(2): 4-5
- Weingart and Swaminathan in Herbert (2021) EM:Rap 21(10): 3-5
VI. Prevention: Aspiration
- Decompress Bowel Obstruction with Orogastric Tube prior to intubation
- Vomiting otherwise may be profuse and result in significant aspiration and very difficult intubation
VII. Resources
- Airway Cam (Levitan)
VIII. References
- Levitan (2013) Practical Airway Management Course, Baltimore
- Weingart et al in Herbert (2016) EM:Rap 16(11): 4-5