strategy for floor intubations

The dose of propofol directly corresponds with how dead the pt is. Usually between 0 and 100mg will do the trick. Just save yourself some grief and use etomidate if pt is hypotensive. If pt is pretty floppy already just induce with some versed. Paralytic isn't necessary for probably 90+% of these intubations, but when needed, is definitely needed.

Every situation is unique and should merit some thought rather than a protocol. That's what separates you from a nurse. Start by evaluating the situation. Is this a code (cardiac arrest, resp arrest, unstable vitals, etc) or not? Is the patient awake at all/making any resp effort? Or is this some guy who's slowly wearing himself out, but not in any immediate danger? Other important thing to look at is airway exam. Are you going to be able to DL this person in likely suboptimal conditions (laying halfway down some floor bed that's not plugged in with your suction across the room and the O2 tubing stretched to the breaking point)? If you have any questions about this, get some help/airway adjunct/surgeon there ASAP.

If there's no emergency, I learn a little about the patient, explain to him/her (and the rest of the room) what I'm gonna do. If the airway is suspicious, I decide if I'm gonna do this awake vs asleep and get some toys. Then I preox the heck out of them and proceed. What drug(s) you use again depend on the whole picture. I tend to use propofol for most people, titrated or not (depending on RSI, etc) but I would say I use more etomidate on the floor than in the OR. This is probably because most people I get called to intubate outside the OR are sicker and/or I don't know much about them. As far as relaxant, you know the (contra)indications for these. The doses are the same as in the OR, but I tend to err on the high side on the floor so I get my one good look.

If there's an actual code with no resp effort or chest compressions going on, I usually just take a look without any drugs. I did once have a guy in pulseless VT (no pulse by palpation or art line) who I tried to intubate without drugs, but the medicine resident's chest compressions were so effective that he'd start talking/resisting when compressions were happening (though was "dead" and unresponsive during pulse checks/switching out thumpers). That's the only time I ever gave an induction agent to a pulseless person.

The in-betweent people (i.e. fading fast with a sat of 60%) sometimes get a little midaz vs 2-3 cc prop or etomidate with a little sux/roc/brutane and a loud, reassuring explanation of what I'm doing.

Anyway, the point is, there are a bunch of "right" ways to do this. Just evaluate the situation and think it through. That's what a consultant anesthesiologist does (or so the ABA says).

PS-maybe I trained at some mamby-pamby hand-holding program, but we weren't sent out to do floor intubations without backup 2 months into CA-1 year. seems a bit premature to me.

castafari said:

strategy for floor intubations .

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While these are basic housekeeping considerations on the grand scheme of things, I suggest taking two seconds to ascertain these items when walking into the room:

1. is there actually a functioning suction cannister, tubing, and Yankeur ready, along with an Ambu bag and oxygen regulator/flow-meter on the wall?

2. can the decorative head of the bed be yanked upwards, out of the bed frame, and set aside? Most can be, reducing the need for you to become a gymnastic gumby as you intubate.

3. if time allows, also raise the bed to your preferred height and make sure the brake is engaged.

These things are sometimes overlooked in all the activities happening when you arrive at a code. I use an obscene (and thus easily remembered) mneumonic covering those checklist things when walking into a code (or OB epidural) room.



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castafari said:

2. The other school of thought never paralyzes anyone ever. They mix Etomidate and Propofol for each pt. Or if the pt's BP can tolerate it, then Propofol only. The Propofol is used with the Etomidate to try to relax airway reflexes enough to have a decent view at intubation. This group also seems to like baby doses of Propofol. Far less then we ever use in the OR during induction

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What's the idea of behind using both etomidate and propofol? What does propofol add to etomidate that another mg or two of etomidate can't? When I do floor/ICU intubation by myself, I tell the person pushing exactly how much I want-none of the gentle titration BS-so propofol is harder to use. I've done intubation with only versed and fentanyl. I usually paralyze (if I'm alone) except when I'm not: if the airway smells fishy at all and there is time, I wouldn't be doing it by myself. The idea of not burning bridges by not paralyzing or using sux instead of roc is false when the patient has two feet in the toilet.

Welcome to anesthesia, no recipe book here. It's rough for you and not entirely safe for the patients to be doing this alone as a CA1. Too early to play cowboy. I hope that when you said "solo" you meant you had the option of calling back up.

For the past 5 years I have just always taken the glidescope with me to floor intubations. Stress melts away. Usually carry a good LMA or intubating LMA as well.

B-Bone said:

PS-maybe I trained at some mamby-pamby hand-holding program, but we weren't sent out to do floor intubations without backup 2 months into CA-1 year. seems a bit premature to me.

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Have to say that I agree completely with this. Even as a CA2 I would feel like I was going to barf when the airway pager went off. I certainly hope you've got an attending or upper level resident with you for these airways. I have run into some nasty airways out on the floors, I can't imagine doing that as a early CA-1.

Lightwand said:

Have to say that I agree completely with this. Even as a CA2 I would feel like I was going to barf when the airway pager went off. I certainly hope you've got an attending or upper level resident with you for these airways. I have run into some nasty airways out on the floors, I can't imagine doing that as a early CA-1.

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CA1 for me: spend a weekend alone at the VA. Middle of the night call to intubate. Massive pumpkin-headed guy down in one of those beds with the blow up mattress. Except the matress has no air and he's down in a hole. I can remember it like yesterday.

Not a good outcome.

Just do your best.

all good recs above. I am really having issues with mixing etomidate and propofol for urgent and emergent intubations on the floor. My recipe for floor intubations is to keep it as simple and safe as possible. Mixing induction agents seems like just the opposite. Can't think of any real indication for it like mentioned above. Just complicates matters and I want to know that whatever drugs and doses I chose will be administered easily without too much calculation/mind work involved. If a dilution needs to occur and I am not in a place or too busy with the airway to do it (i.e. ketamine for a 3 kg kid comes to mind)-- I double and triple check the dose, dilution and ccs to be given with the nurse/resident/fellow giving the drug, particularly when they are not anesthesia folks because if they aren't used to doing it fast like we are, they get nervous and are more likely to make mistakes.

If they look like they are tiring out and need intubation, just wait 30 minutes and come back. That way you don't have to think about what drugs to give. CO2 is a great anesthetic. Just kidding. At my training hospital we were not allowed to push any paralytics without an attending present. Department policy.

This may be a little off topic, but one thing that I didn't appreciate enough as a CA-1 that I did more towards the end is the fact that you are a competent physician. If someone calls you for an intubation and you don't think the patient needs intubated, don't do it. Have an intelligent conversation with whoever wants them intubated and come to a conclusion that is best for the patient. As said before, this is the stuff that sets you apart from a CRNA that will just show up and stick the tube in and leave. I have had several conversations with medicine residents who want some end-stage lung-CA patient or COPD patient intubated and I know that if I put that tube in it will never come out, except through their neck. Told them they need to have a quick "come to Jesus" conversation with the pt. and family and see if this is really what they want. Many times they say no thanks, and that is probably the best thing for the patient. Also, if it is a pt. on the floor that is tiring out or struggling a little, transfer them to the ICU before you intubate them. More controlled than the floor and usually have access to more equipment and drugs if you need them. Again, usually have to convince the medicine or surgery resident that that is probably in the patient's best interest rather than intubating them on the floor and then transporting them. If you think they can safely tolerate the transfer before intubating them that is often the safest option.

I have 3 floor/ICU intubations that I will never forget. Will share later.

imfrankie said:

CA1 for me: spend a weekend alone at the VA. Middle of the night call to intubate. Massive pumpkin-headed guy down in one of those beds with the blow up mattress. Except the matress has no air and he's down in a hole. I can remember it like yesterday.

Not a good outcome.

Just do your best.

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I know I shouldn't laugh because I've been there...you name it...90 yo in resp failure all scoliotic like a pretzel with hx of multi level neck fusion-severe AS, no IV-CERTAINLY no A-line-septic from his pneumonia who never managed to show up for his much needed valvuloplasty....

All that aside...it's just the VA...stirs up memories of my intern yr-being called to pronounce someone who had easily been dead 10 hrs...and apparently his death was only noticed at shift change

My understanding (correct my if I'm wrong) is that propofol is so tenuously soluble to begin with that mixing it is actually inconsistent with the drug company recs because it changes the globule size/surface area and changes it's pharmacodynamics as a result. Don't know if it makes any difference clinically. I see a lot of people mix lidocaine with propofol in the OR, as well. I prefer the bastardized Bier block approach of putting my hand proximal to the IV on their vein and putting in the lido 30 seconds before. I'm way early to have the experience I need to make a more informed decision on my future practice, though.

As far as floor, propofol is way too much of a CV depressant to use unless you are going to chase it with phenylephrine or something right after in most urgent cases... even just a sick person coming to the OR from the ED urgently in a relatively controlled fashion would get dangerously hypotensive w/ the prop.

BobBarker said:

The dose of propofol directly corresponds with how dead the pt is. Usually between 0 and 100mg will do the trick. Just save yourself some grief and use etomidate if pt is hypotensive. If pt is pretty floppy already just induce with some versed. Paralytic isn't necessary for probably 90+% of these intubations, but when needed, is definitely needed.

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I totally agree, if you need to intubate on the floor it's probably because the pt is almost dead. I'd give lower end doses of propofol, You could even probably intubate some of them with just two of versed if they had an easy airway, give 50mcgs of fentanyl with that and they're now apnic. Just pre-oxygenated or at least denitrogenate them before you give the drugs unless you have an ambu bag set up and can take over the airway, you might need to use some muscle.

I admit that I haven't read all the posts here so if this has been touched on,I apologize.

My approach, KISS.
Give propofol and sux. Period.

If they are hypotensive add neo.

If they are unresponsive give just sux.

If sux contraindicated, give Roc.

If you cant intubate, the muscle relaxant will make mask ventilation easy.

If difficult airway then do your usual difficult intubation routine.

KISS!

Here's what I find helpful for a newbie resident:

Have a go-to formula that you can fall back on all the time. This means same blade, same head position, same drugs. After you've done 10 or so floor intubations, you can then start to vary things like the drugs etc.

My "go-to" formula for urgent floor intubation:
- If they're on BIPAP, put 'em on FiO2 100% while you're setting up (they won't think to do it).
- 2-3cc of ANY induction agent for the patient in respiratory failure. (ex: propofol, midazolam, ketamine, etomidate). Any agent is ok as long as you don't use too much of it, and a couple cc's are usually enough for the obtunded hypercarbic respiratory failure patient.
- Rocuronium 1.2mg/kg assuming no difficult airway on exam.
- Phenylephrine boluses 40-200mcg during airway management.
- Use your favorite blade and put the tube in.

For code blues:
- Do not ask for "hold chest compressions" in order to do laryngoscopy.
- If unable to see enough to pass tube, low threshold for LMA. The new ACLS guidelines state LMA is an acceptable airway during ACLS. Tube is obviously better if achievable in a TIMELY fashion, but LMA with some ventilation is better than no ventilation at all.
- Airway is no longer first (ABC) in ACLS -- it's second! The order is now C-A-B and circulation comes before airway. Keep the chest compressions going.

What is the protocol for intubating post-ictal patients with confusion and altered mental status?

If nobody responds, I'll look it up and post my results.

cfdavid said:

What is the protocol?

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Not intubating them?

RussianJoo said:

Just pre-oxygenated or at least denitrogenate them

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How else do you denitrogenate? Bring up a tank of helium?

Jennyboo, my understanding is that the thought behind not holding chest compressions in order to secure an airway during CPR (i.e. CAB) is that most people simply can't mask ventilate effectively or intubate quickly/properly. I think that if someone with such expertise (i.e. anesthesiologist, senior resident, etc...) is available, things change a bit. In these situations, I'll typically do direct laryngoscopy while CPR is in progress and, if needed, ask for compressions to be held as I pass the ETT (typically less than 30 seconds).

jennyboo said:

For code blues:
- Do not ask for "hold chest compressions" in order to do laryngoscopy.
- If unable to see enough to pass tube, low threshold for LMA. The new ACLS guidelines state LMA is an acceptable airway during ACLS. Tube is obviously better if achievable in a TIMELY fashion, but LMA with some ventilation is better than no ventilation at all.
- Airway is no longer first (ABC) in ACLS -- it's second! The order is now C-A-B and circulation comes before airway. Keep the chest compressions going.

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I would like to add to the bolded statement. The ACLS guidelines are perfectly appropriate for the out of hospital arrest or the code without airway personnel, but since many of these codes are directly related to respiratory failure, you will not get a patient back without an airway or some form of ventilation, thats all there is to it. acceptable masking, LMA, tube, whatever, you cant ignore ventilation

Ive asked for people to hold chest compressions for up to 5 seconds before. It doesnt feel good while you are doing it, but it frees me up to do something else and I know that I can supply much needed administration of oxygen and removal of CO2.

lushmd said:

Jennyboo, my understanding is that the thought behind not holding chest compressions in order to secure an airway during CPR (i.e. CAB) is that most people simply can't mask ventilate effectively or intubate quickly/properly. I think that if someone with such expertise (i.e. anesthesiologist, senior resident, etc...) is available, things change a bit. In these situations, I'll typically do direct laryngoscopy while CPR is in progress and, if needed, ask for compressions to be held as I pass the ETT (typically less than 30 seconds).

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exactly my point. im still prioritizing the airway, usually that can happen in parallel with chest compressions, so it isnt a big deal

arch guillotti said:

covered in detail before dude, sheesh

floor intubations, any advice?


succinylcholine in emergent floor intubations


floor intubations

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agreed.

RxBoy said:

How else do you denitrogenate? Bring up a tank of helium?

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Haha good one

Yes, the ACLS protocols are for amateurs.

We are professionals. Secure the airway.

RxBoy said:

How else do you denitrogenate? Bring up a tank of helium?

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i don't know to some attendings pre-oxiginating is having a pt breath 100% o2 for a few min while hooking up the monitoring equipment, and denitrogenate by having them take a few big breaths... But I guess having the pt take 4 big breaths both pre-oxygenates and denitrogenates them at the same time.

The first thing I do on a floor intubation is look the patient up in our electronic anesthesia record database to see if I can find the documentation of a prior intubation. It takes me about 2 minutes and I can tell if they were a grade I intubation by the most junior person in the world 6 months ago or if they were a majorly difficult glidescope that required 2 people to ventilate.

It preps me for what I'm walking in to.


As for my plan when I get there, it all depends. It's the same as coming to the OR for an elective procedure, my time course just gets sped up a bit if it's a code compared to an elective intubation for somebody in impending respiratory failure.

Most people I'm reasonably sure I can intubate after checking their past anesthesia records and doing a quick airway exam. They usually get an IV induction and some succinylcholine (if no contraindications) and a quick DL or glidescope leading to intubation.

Other people I'm not so sure about and I might try to topicalize the airway and give a little IV ketamine followed by a glidescope look.

I've also had to do an awake nasal FOI on a 500 lber with CHF flare and on BiPap and not really mentating terribly well because of high pCO2. The CO2 helped make it a pretty easy nasal FOI and he quickly perked up after being ventilated for about 2 minutes.


You just gotta tailor the approach to the patient, the same way you do in the OR. The only difference is if they are already coding I just throw a blade (or glidescope) in and go for it.

RussianJoo said:

i don't know to some attendings pre-oxiginating is having a pt breath 100% o2 for a few min while hooking up the monitoring equipment, and denitrogenate by having them take a few big breaths... But I guess having the pt take 4 big breaths both pre-oxygenates and denitrogenates them at the same time.

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Just teasing you dude. In both cases you are denitrogenating and preoxygenating essentially increasing the total volume of O2 in your FRC. A typical ITE question would be which is the most effective? Hint: Barash has the answer.

RussianJoo said:

i don't know to some attendings pre-oxiginating is having a pt breath 100% o2 for a few min while hooking up the monitoring equipment, and denitrogenate by having them take a few big breaths... But I guess having the pt take 4 big breaths both pre-oxygenates and denitrogenates them at the same time.

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Um...I don't really understand your separation of preoxygenation and denitrogenation as different processes. Applying 100% oxygen does both. They're the same thing. Replacing N2 with O2. Am I missing something here?

fakin' the funk said:

Um...I don't really understand your separation of preoxygenation and denitrogenation as different processes. Applying 100% oxygen does both. They're the same thing. Replacing N2 with O2. Am I missing something here?

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nope you're not missing anything. You're correct.