Code Intubations

[DrRobert]

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It seems that most academic centers have anesthesia carry the code pager to address all emergency airway situations throughout the hospital.

Is this common in private practice?

These can be some of the scariest airways with suboptimal conditions/equipment/information.

It would be great if I didn't have to deal with these nightmares when I get out of training.

 

[Planktonmd]

It seems that most academic centers have anesthesia carry the code pager to address all emergency airway situations throughout the hospital.

Is this common in private practice?

These can be some of the scariest airways with suboptimal conditions/equipment/information.

It would be great if I didn't have to deal with these nightmares when I get out of training.

It's not common in private practice for anesthesiologists to respond to codes. That's usually what ER physicians do.
I don't consider intubations during a code to be particularly difficult, just stick the laryngoscope in and put the tube where it belongs.

 

[coprolalia]

I don't consider intubations during a code to be particularly difficult, just stick the laryngoscope in and put the tube where it belongs.

I agree. This is what MilMD would call a "no lose" situation. The patient is in extremis and you just grab the tube and put it in the hole. You can't get it in, not gonna reflect negatively on you... especially if it is a 900lb beached whale. You didn't make the patient code, after all.

-copro

 

[BobBarker]

I'm a 3rd year student, and my first intubation attempt was on a code at the beginning of the month. First day of my rural hospital month. The overhead page for the code was very quiet for some reason and I didn't hear it in the dictation room. I stroll out, and a nurse tells me about it. I walk in and my preceptor and a doc that I shadowed in undergrad are in the room. They aren't getting good ventilation with the bag/mask (no teeth, beard, rotund). He needs to be intubated. Doc says, "You want to do it?", I say "Sure." They hand me a Mac 4. He asks "Ever done this before?", I say "Only on a dummy." They have the guy with the HOB still elevated. He's sitting up. I give it a crack anyways. Nothing but metal and tongue. I pass off the blade. They lower the HOB, put a backboard under him, and get a better view. They can't pass the tube, because of abundant redundant tissue. I suggest a Miller 2 or 3, they say "What's that??" The kit isn't complete and they don't have a 2 but a 3 is found. Both docs and a paramedic strike out. I slam a combitube in and we continue CPR. He never was in a shockable rhythm. Asystole all of the way. First code, first intubation attempt, first death, first day.

 

[thegasman]

ER docs respond to the codes here - I really don't miss that code pager from residency, but the one time i did get called to help it was a bloody mess. I do get called for elective/semielective icu intubations.

 

[Trisomy13]

These can be some of the scariest airways with suboptimal conditions/equipment/information.

It would be great if I didn't have to deal with these nightmares when I get out of training.

And here I thought that's why we were trained to be the airway experts

 

[urge]

Patients don't code in private practice.

 

[Planktonmd]

Patients don't code in private practice.

 

[coprolalia]

Patients don't code in private practice.

Right. Instead, they either acutely undergo a temporary or permanent inhibition of normal homeostasis.

-copro

 

[DrRobert]

I wish it was always as easy as taking a look a putting the tube in.

It seems the majority of codes I've been to on the wards involve:

1. No one seems to know any medical information about the patient except "they were found unresponsive".

2. There are usually 20 people in the room.

3. The patient is typically in the worst position imaginable for airway management. Some of the hospital beds don't even allow you to reach the patient's head easily.

4. There is usually no pulse ox, no suction, no laryngoscope, no ETTs.

5. The oropharynx always seems to be bloody.

6. With my luck, all these patients have huge tongues.

7. The code team is always reluctant to stop chest compressions so I can take a look.


All of this coupled with the stress of a dying patient makes these intubations much more difficult than those in the OR.

 

[pillowhead]

Blood in the oropharynx has been my major issue in the few codes i've been to so far. I've literally had to pull clots out of the oropharynx with my fingers. Suction in floor rooms is weak at best and a yankeur can't suction big chunks of dried blood. I hate it. I absolutely despise code airways. There's 20 people in the room and yet somehow, no one seems to be doing anything remotely helpful.

 

[Trisomy13]

I wish it was always as easy as taking a look a putting the tube in.

It seems the majority of codes I've been to on the wards involve:

1. No one seems to know any medical information about the patient except "they were found unresponsive".

2. There are usually 20 people in the room.

3. The patient is typically in the worst position imaginable for airway management. Some of the hospital beds don't even allow you to reach the patient's head easily.

4. There is usually no pulse ox, no suction, no laryngoscope, no ETTs.

5. The oropharynx always seems to be bloody.

6. With my luck, all these patients have huge tongues.

7. The code team is always reluctant to stop chest compressions so I can take a look.


All of this coupled with the stress of a dying patient makes these intubations much more difficult than those in the OR.

the above reasons are what make code intubations so exciting...

i do understand your frustration, but i think i have a different perspective. code intubations seem to be the rare occasions where you can walk into a room and start barking orders and taking command, and know that you are probably the most capable physician in the room.

 

[militarymd]

Hey....are you secretly training at my PP hospital????

Seriously....like what Cop said about what I said....

You 'll get over your angst.....










or not.

I wish it was always as easy as taking a look a putting the tube in.

It seems the majority of codes I've been to on the wards involve:

1. No one seems to know any medical information about the patient except "they were found unresponsive".

2. There are usually 20 people in the room.

3. The patient is typically in the worst position imaginable for airway management. Some of the hospital beds don't even allow you to reach the patient's head easily.

4. There is usually no pulse ox, no suction, no laryngoscope, no ETTs.

5. The oropharynx always seems to be bloody.

6. With my luck, all these patients have huge tongues.

7. The code team is always reluctant to stop chest compressions so I can take a look.


All of this coupled with the stress of a dying patient makes these intubations much more difficult than those in the OR.

 

[9french]

I wish it was always as easy as taking a look a putting the tube in.

It seems the majority of codes I've been to on the wards involve:

1. No one seems to know any medical information about the patient except "they were found unresponsive".

2. There are usually 20 people in the room.

3. The patient is typically in the worst position imaginable for airway management. Some of the hospital beds don't even allow you to reach the patient's head easily.

4. There is usually no pulse ox, no suction, no laryngoscope, no ETTs.

5. The oropharynx always seems to be bloody.

6. With my luck, all these patients have huge tongues.

7. The code team is always reluctant to stop chest compressions so I can take a look.


All of this coupled with the stress of a dying patient makes these intubations much more difficult than those in the OR.

Another PP doc where the ER doc responds to code intubations. Although we are the airway experts, if we are in the O.R. we do not have the ability to be in two places at once. On the otherhand, there is always at least one E.R. doc free. We are, however, the first call to "urgent" and "elective" intubations (I don't believe in either of those terms).

As far as the suboptimal conditions, that is universally true. There are two pieces of advice I can give. The first is that often patients are placed on 100% O2 nonrebreather for a long time prior to you being called. This dries secretions. Have a pair of Mcgill forceps available. On more than one occassion I have needed to pull out a long cast of the trachea made of dried secretions and blood.

The second piece of advice is to realize that intubation is not a first line tx for a code. New ACLS guidelines do not want you to stop compressions for intubation. Per guidelines, if you have the ability to mask ventilate, just do that initially. Once you regain a rhythm, that's when you ideally should place the tube. In reality, I would not always wait that long, but I would not stop chest compressions more than very briefly, i.e. 10 seconds, for intubation.

 

[cchoukal]

agree with above. I usually do my suction and first look during compressions and wait until the meditrons pause for pulse and rhythm checks to intubate. if I can mask effectively while I wait, I will. there are exceptions to this, but that's my usual plan.

 

[nutmegs]

I'd just be happy if I didn't walk in to find compressions in progress, three people digging for central venous access, and no ambu bag or O2 mask in sight.

 

[rsgillmd]

I wish it was always as easy as taking a look a putting the tube in.

It seems the majority of codes I've been to on the wards involve:

1. No one seems to know any medical information about the patient except "they were found unresponsive".

If they're dead, you're not going to push any drugs anyway, so who cares about medical information? Only thing I may ask during a real code if they are a surgical patient is if they are a known difficult intubation. We have many faults in my hospital, but if a patient was a difficult intubation, everyone taking care of that patient knows it.

2. There are usually 20 people in the room.

3. The patient is typically in the worst position imaginable for airway management. Some of the hospital beds don't even allow you to reach the patient's head easily.

This is a good excuse to lose weight so you can sneek into tight spots. Also, sometimes you just have to force your way through the crowd to get to the head. Heck, once I intubated standing at the side of the bed because I didn't want to stand in the mess at the head of the bed. But that patient was skinny and the room wasn't crowded yet. I've even intubated some patients (for urgent intubations -- not codes) in the sitting position because they couldn't lie flat I've even done it when the patient was on the floor after choking on a piece of chicken in the Psych dining room. You just have to be flexible but willing to take charge when necessary.

4. There is usually no pulse ox, no suction, no laryngoscope, no ETTs.

You don't have an intubation box with laryngoscopes and ETTs on your code cart? If you don't, then do something about it. Your hospital probably has a code committee -- make them aware of the issue. This way you don't have to drag a whole box around. I carry a backup laryngoscope in my pocket, but I'm been burned before with dead batteries.

As far as the suction goes, that's a major problem at our institution also. I'm sure the two of us are not the only ones either. This is hard to change.

5. The oropharynx always seems to be bloody.

6. With my luck, all these patients have huge tongues.

7. The code team is always reluctant to stop chest compressions so I can take a look.

All of this coupled with the stress of a dying patient makes these intubations much more difficult than those in the OR.

Can't help you much with 5 and 6. As far as 7, usually when I walk in the room I hear someone say "Thank goodness, anesthesia is here." Either way, I announce my presence and once I get to the head, I tell the person doing compressions to keep going until I tell them to stop. Usually I don't need to have them stop, but occasionally it's necessary. You just have to be speak up if they don't stop when you ask them to. I'm 5'4" and 135 lb, and mostly a soft-spoken person. However, I will speak up in these situations if it seems I'm not being heard. If I speak up loudly and forcefully, they'll listen to me. This is because a) I make it clear that I'm calm and in charge the moment I walk in the room, and b) the person doing the compressions is usually just a scared intern or medical student who needs instructions.

As for your last paragraph, I'll say what I told my students when I used to teach CPR: they're dead already. You can't make them any worse. You can only hopefully make them better.

Additionally even if it's a non-cardiac arrest situation, I'm sure you've probably had your share of stressful intubations in the OR. If you haven't, then you will. Being airway experts and being able to perform under pressure is a large part of what defines our specialty.

 

[jwk]

If they're dead, you're not going to push any drugs anyway, so who cares about medical information?

As for your last paragraph, I'll say what I told my students when I used to teach CPR: they're dead already.

Sorry, that seems a little absurd. You may not care about it if the only thing you're dealing with is the airway, but if you're running the code, of course you want to know some history. "Gee doc, we just put in a central line and he quit breathing about two minutes later", or similar comments, might just be of some importance.

 

[rsgillmd]

Sorry, that seems a little absurd. You may not care about it if the only thing you're dealing with is the airway, but if you're running the code, of course you want to know some history. "Gee doc, we just put in a central line and he quit breathing about two minutes later", or similar comments, might just be of some importance.

I 100% agree with you if I'm running the code, but in my institution we put the tube in, verify it, and leave. I assumed that was the situation that the original poster was referring to.

On some occasions I've had to run a code in July/August months but then you start asking the appropriate questions. If I'm running a code, I try to assign anyone in the room a responsibility: get the chart, find the latest labs, insert central line, etc. Anyone who is not assigned a role is thanked for their help and asked to step out of the room. It's a variation of what I did when I worked EMS: take a situation that is out of control and turn it into something resembling a controlled situation.

You could even argue with my last sentence if you wanted to -- you can decrease a person's chances of recovery if you don't effectively mask ventilate, have an unrecognized esophageal intubation, not knowing drugs/doses to give, etc. But I don't think the original poster is concerned about those things. He just seemed more stressed than anything else about the pressure of having to intubate a patient under suboptimal conditions.

 

[coprolalia]

I 100% agree with you if I'm running the code, but in my institution we put the tube in, verify it, and leave.

How do you "verify" it? Before you answer, think about that for a second or two.

-copro

 

[nutmegs]

How do you "verify" it? Before you answer, think about that for a second or two.

-copro

bilateral breath sounds and chest rise, lack of rapidly expanding stomach, +/- CO2 change if they have good compressions going

 

[2ndyear]

Private practice, and we do respond to codes if able. If we are in the OR solo then hospitalist or ER doc. For some reason I do not see near as many codes in the real world compared to residency. I'm guessing it's due in part to rapid responses that actually turn many of these into semi-elective intubations, or maybe the patients aren't as sick.

 

[coprolalia]

bilateral breath sounds and chest rise, lack of rapidly expanding stomach, +/- CO2 change if they have good compressions going

During a code?!?? ALL of those things are unreliable. You won't be able to discern where the chest sounds are coming from in the midst of compression and people barking out orders and whatnot. A stomach rise, very unreliable, may either mean the tube is in the right place or the patient is having agonal movements. EtCO2? Well, you answered that one yourself.

The only way to "verify" the correct placement of the tube during a code is to watch it go through the vocal cords. "And, that, your honor, is exactly what I did." If you goosed it, you didn't have a good view... and you should've continued bag-mask ventilation... or repositioned the laryngoscope.

-copro

 

[rsgillmd]

bilateral breath sounds and chest rise, lack of rapidly expanding stomach, +/- CO2 change if they have good compressions going

As above. I've been lucky, most times I've been able to get sustained EtCO2 (defined in our hospital as change for >=6 breaths). For the occasions that I haven't been able to get CO2, I'll do another DL to confirm that I am seeing the tube going through the cords.

One time I responded to a code and was warned by the medicine resident that the patient is a known difficult intubation due to an anterior larynx. I took one look with Miller 2 and could not get epiglottis out of the way. I had RT ventilate while I prepared LMA Fastrach. I called my attending to get out of bed and bring a fiberoptic. Intubated through LMA Fastrach. Good chest rise, nothing over stomach. However, did not get EtCO2. My attending showed up, and we confirmed tracheal placement using the fiberoptic scope.

Previously if I wanted a digital EtCO2 reading I had to drag a brick of a device with me. Recently the hospital purchased a more portable device -- I think it's called Capnocheck. Haven't had a chance to use it yet but I've heard it's useful.

 

[jwk]

During a code?!?? ALL of those things are unreliable. You won't be able to discern where the chest sounds are coming from in the midst of compression and people barking out orders and whatnot. A stomach rise, very unreliable, may either mean the tube is in the right place or the patient is having agonal movements. EtCO2? Well, you answered that one yourself.

The only way to "verify" the correct placement of the tube during a code is to watch it go through the vocal cords. "And, that, your honor, is exactly what I did." If you goosed it, you didn't have a good view... and you should've continued bag-mask ventilation... or repositioned the laryngoscope.

-copro

Humbly disagree

I place a fair number of tubes where I have poor visibility, sometimes never seeing the cords, but getting the tube in nonetheless. And how do we check for tube placement? Listen to breath sounds and check for ETCO2. Ignore either one of those, code or not, at your own peril. Yes, I realize you won't always get a color change on the little portable CO2 device. But it takes all of 3-5 seconds to squeeze in three breaths after the ETT to listen to each side and over the stomach. If you tell the jury "I'm sure I saw the tube go between the cords" but you don't verify it somehow, I'm not sure you've done yourself much good.

 

[nutmegs]

During a code?!?? ALL of those things are unreliable. You won't be able to discern where the chest sounds are coming from in the midst of compression and people barking out orders and whatnot. A stomach rise, very unreliable, may either mean the tube is in the right place or the patient is having agonal movements. EtCO2? Well, you answered that one yourself.

The only way to "verify" the correct placement of the tube during a code is to watch it go through the vocal cords. "And, that, your honor, is exactly what I did." If you goosed it, you didn't have a good view... and you should've continued bag-mask ventilation... or repositioned the laryngoscope.

-copro

you taking care of my family members??

watching the cuff go through the cords is a given. but so are multiple methods of confirmation. I wonder how many codes you've been to if that's your "verification" though, considering how much bouncing around goes on between the time you pull out your laryngoscope and the RT tapes the bad boy to the poor sucker's face. there is NO single way to verify tube placement, especially in a code. I assumed a competent laryngoscopist. but thanks for the lecture.

 

[coprolalia]

Humbly disagree

I place a fair number of tubes where I have poor visibility, sometimes never seeing the cords, but getting the tube in nonetheless. And how do we check for tube placement? Listen to breath sounds and check for ETCO2. Ignore either one of those, code or not, at your own peril. Yes, I realize you won't always get a color change on the little portable CO2 device. But it takes all of 3-5 seconds to squeeze in three breaths after the ETT to listen to each side and over the stomach. If you tell the jury "I'm sure I saw the tube go between the cords" but you don't verify it somehow, I'm not sure you've done yourself much good.

We're talking about a code, not what you or I would normally do. All those things when you normally put a tube in someone with a beating heart who doesn't have someone wailing on their chest fly out the window.

You see it plunk through the cords, or you can't "verify" any other way that it is in. Sorry.

-copro

 

[Planktonmd]

Here is a simpler way to "verify":
If the patient lives then your tube is most likely in the right place.
If the patient dies it doesn't matter where your tube is.

On a more serious note though: In the absence of cardiac output and ETCO2, auscultation of the chest and the stomach are still valuable as long as you know how to use a stethoscope (many people don't these days).

 

[Arch Guillotti]

The Journal of Emergency Medicine, Vol. 20, No. 3, pp. 223–229, 2001

Title:

CAPNOGRAPHY ALONE IS IMPERFECT FOR ENDOTRACHEAL TUBE
PLACEMENT CONFIRMATION DURING EMERGENCY INTUBATION

"literature review demonstrated no sole method of tube
placement confirmation is completely foolproof."

"Multiple methods of tube placement confirmation are superior
to any single method because no single method has
perfect accuracy."

 

[militarymd]

Here is a simpler way to "verify":
If the patient lives then your tube is most likely in the right place.
If the patient dies it doesn't matter where your tube is.

On a more serious note though: In the absence of cardiac output and ETCO2, auscultation of the chest and the stomach are still valuable as long as you know how to use a stethoscope (many people don't these days).

You make an excellent point.


We have a PP poster here who freely admits that more than half of his partners don't even carry a stethescope...let alone examine patients.

 

[coprolalia]

I think the bigger point for the noobs and the juniors on this forum is that lack of end-tidal CO2 or good bilateral breath sounds doesn't mean the tube is in the wrong spot, and that you should subsequently automatically pull it and re-try.

If you actually watched it go through the cords, then this is probably your best chance at "confirming" proper tube placement during a code. If you're not sure, but you get end-tidal CO2 and the patient perks up you're probably in the right spot.

I still listen to the chest (when I can) during codes and put a capnography monitor on the end of the tube. Don't get me wrong. I just don't rely on these things to tell me definitively the tube is in the right spot.

-copro

 

[coprolalia]

We have a PP poster here who freely admits that more than half of his partners don't even carry a stethescope...let alone examine patients.

Agreed. I had an elderly patient who was coming to the OR for a semi-urgent surgery recently. I listened to her chest and heard a crescendo-type grade II-III/VI murmur at the left sternal border. Looking through the chart, I was the first one who'd noticed this out of four other doctors - including an attending - who'd examined her.

You'd be proud, though, Mil. We still did the case.

-copro

 

[jwk]

I think the bigger point for the noobs and the juniors on this forum is that lack of end-tidal CO2 or good bilateral breath sounds doesn't mean the tube is in the wrong spot, and that you should subsequently automatically pull it and re-try.

If you actually watched it go through the cords, then this is probably your best chance at "confirming" proper tube placement during a code. If you're not sure, but you get end-tidal CO2 and the patient perks up you're probably in the right spot.

I still listen to the chest (when I can) during codes and put a capnography monitor on the end of the tube. Don't get me wrong. I just don't rely on these things to tell me definitively the tube is in the right spot.

-copro

I've seen too many instances over the years where "I'm sure I saw the tube go between the cords" and the tube was NOT in the trachea. Happens far too frequently in both pre-hospital care and teaching institutions, far less frequently in private practice. Yes, I absolutely love watching that ETT slide atraumatically through the cords. Yet I still listen, check for CO2, etc. Just because it's a code doesn't mean you can't verify. You most certainly can hold CPR and tell everyone in the room to shut up if that's what it takes to be able to listen to breath sounds.

 

[Planktonmd]

Agreed. I had an elderly patient who was coming to the OR for a semi-urgent surgery recently. I listened to her chest and heard a crescendo-type grade II-III/VI murmur at the left sternal border. Looking through the chart, I was the first one who'd noticed this out of four other doctors - including an attending - who'd examined her.

You'd be proud, though, Mil. We still did the case.

-copro

Almost 50% of the elderly population has some sort of systolic murmur if you listen carefully.
An isolated systolic murmur in an elderly patient is almost never a reason to cancel a case.