your approach in intubating this hypoxic patient?

[Painter1]

so you get an obese female in her 60s with multiple med problems after fall.

a trauma was activated.

the patient has hx of renal failure and is on dialysis. she's noted to be hypoxic not improving on non-rebreather. o2 sat is 86% on non-rebreather at 15 liters.

cxr with question of bilateral pna versus edema but you also think of hemorrhage. no pneumo.

patient is otherwise awake and alert but with mild tachypnea.

decision to intubate is made.

in recap, you have a morbidly obese female with multiple med problems, hypoxic on non-rebreather. patient has c-collar but she has a short fat neck.

what's your approach?

straight RSI eventhough you're going in with a patient who looks like a tough intubation with an already low o2 sat not improving with bag mask?

do you shot her up with etomidate and take a look without paralysing?

do you bipap her to see if you can get the o2 sat up then RSI if you do get o2 sat up?

any other suggestions?

i'll tell you how this churned out after you inputs.

to note, changes have been made to case to keep case unindentifiable and confidential

---

Members don't see this ad.

 

[southerndoc]

Sedatives without paralytics have been shown to worsen success rates for intubation.

What's her Mallampati score?

What do you have available? Bougie? Fiberoptic? GlideScope?

What I would do will depend on Mallampati and available equipment.

 

[FDNewbie]

so you get an obese female in her 60s with multiple med problems after fall.

Sounds like our baseline patient population

a trauma was activated.

NOW things get interesting

the patient has hx of renal failure and is on dialysis.

So succs is out. Err on the side of caution; hyperkalemia is a serious concern.

she's noted to be hypoxic not improving on non-rebreather. o2 sat is 86% on non-rebreather at 15 liters.

Sounds like she's buy a tube.

cxr with question of bilateral pna versus edema but you also think of hemorrhage. no pneumo.

patient is otherwise awake and alert but with mild tachypnea.

decision to intubate is made.

Right choice. ABCs = Airway comes first. Gotta secure the airway and proceed with the rest of the trauma eval. Definitely don't want to have to mess around with the airway under suboptimal conditions in the scanner or during transport etc. Plus, you wanna look out for the patient. Hypoxia in trauma is BAD.

in recap, you have a morbidly obese female with multiple med problems, hypoxic on non-rebreather. patient has c-collar but she has a short fat neck.

what's your approach?

straight RSI eventhough you're going in with a patient who looks like a tough intubation with an already low o2 sat not improving with bag mask?

Negatory. Succs is a bad idea, and even with an iStat, which can be off. Now if she JUST came from dialysis & had completed her dialysis...

But still, the other reason succs may be a no-no is your post obviously conveys your hesitancy about securing her airway. Succs = the point of no return. Don't do it unless you're sure.

do you shot her up with etomidate and take a look without paralysing?

I think that's your safest bet for sure.

do you bipap her to see if you can get the o2 sat up then RSI if you do get o2 sat up?

Can't. If you're running the trauma right, you haven't proceeded to BCDE yet cuz you haven't finished with A. Definitively take care of A. Don't put it on "hold" or "come back to it. Address life-threatening issues as they arise during your trauma eval, DEFINITIVELY.

any other suggestions?

- Have your suction ready
- Have multiple ppl @ the head of the bed ready to help you
- Place the patient in a little T-bird (no, not reverse T-bird; actual T-bird, with head higher than the feet). This causes gravity to help take some of the weight off of the neck & upper chest from on the airway to drooping further down. Helps your view a bit.
- Have the bed up at the right height (around where your xyphoid process is)
- Have a colleague hold C-spine while you remove the collar to ensure maximal mouth opening to provide you with the best view
- Have a bougie on-hand
- Have your glidescope ready, should you need it
- Have Anesthesia ready, should you need them
- Take a nice slow, deep breath to reduce your anxiety. The patient's already in extremis; you being so as well won't help any.
- Induce, take a look, and succeed.

i'll tell you how this churned out after you inputs.

I'm sure you did fine man. 90% - 95% of all procedures is setup & positioning. Unfortunately, trauma patients place you at a disadvantage for that because of the c-spine precautions. But when all is said & done, only about 1% of all intubations are truly difficult airways, despite how tough they may LOOK (from the outside). And I've personally found that number to hold true. Only 1 outta every 100 or so tubes required a bougie or other advanced/adjunctive tool to secure the airway. Most of the time I'm surprised how easy a tube was based on how difficult the patient APPEARED to be. But better to prepare adequately & be safe...than sorry.

 

[FDNewbie]

Sedatives without paralytics have been shown to worsen success rates for intubation.

Not familiar with that data. Won't second guess it either, but aside from keeping in mind the need to time your intubation with the opening of the vocal cords, I haven't had any difficulty with this method the handful of times I've used it. If anything, I think it's an excellent teaching tool, cuz it buys your student/lower level resident time to get their bearings while holding decent sats, cuz the patient's still breathing.

Mind sharing that data btw, just for my education? I'm curious as to why it has worse success rates. I'm guessing cuz the patient isn't as relaxed, which doesn't give you the best view possible?

What's her Mallampati score?

Data shows they're not very helpful: http://www.ncbi.nlm.nih.gov/pubmed/16717341. Conclusion of the article: "Used alone, the Mallampati tests have limited accuracy for predicting the difficult airway and thus are not useful screening tests."

 

[xaelia]

McNinja and I talked about something relevant the other day - does anyone have any data or anecdotal experience putting the bougie through an LMA?

 

[Painter1]

thanks so far for the replies. i'd be happy to keep hearing others feedback/input.

i opted to use only etomidate with use of glidescope.

i went this route because in the past i had a similar case where after inducing and paralyzing a similar patient, the already low 02 sats plummeted and the patient proofed difficult to bag and intubate. in that case, i ended up using an LMA.

for this case, things started well, patient was nice and sedated after etomidate, able to see cords with glidescope, passed et tube, but then the patient was impossible to bag. it was like pressing your hand through a rock when trying to bag. turns out, the patient appears to have had a masseter spasm and was clenched down on the et tube.

placed nasal trumpet bilaterally, gave rocuronium, teased the et tube out, bagged through the nasal trumpets, was then able to re-intubate again with glidescope.

I'm thinking of maybe using versed without paralytic next time instead of etomidate without paralytic in similar case. turns out there are documented cases of masseter spasm with etomidate.

anyone else?

 

[SoCuteMD]

- Place the patient in a little T-bird (no, not reverse T-bird; actual T-bird, with head higher than the feet). This causes gravity to help take some of the weight off of the neck & upper chest from on the airway to drooping further down. Helps your view a bit.

Just FYI, it's T-burg (or Trendelenburg). And Trendelenburg position is feet higher than head. Reverse Trendelenburg is head higher than feet.

 

[Groove]

so you get an obese female in her 60s with multiple med problems after fall.

a trauma was activated.

the patient has hx of renal failure and is on dialysis. she's noted to be hypoxic not improving on non-rebreather. o2 sat is 86% on non-rebreather at 15 liters.

cxr with question of bilateral pna versus edema but you also think of hemorrhage. no pneumo.

patient is otherwise awake and alert but with mild tachypnea.

decision to intubate is made.

in recap, you have a morbidly obese female with multiple med problems, hypoxic on non-rebreather. patient has c-collar but she has a short fat neck.

what's your approach?

straight RSI eventhough you're going in with a patient who looks like a tough intubation with an already low o2 sat not improving with bag mask?

do you shot her up with etomidate and take a look without paralysing?

do you bipap her to see if you can get the o2 sat up then RSI if you do get o2 sat up?

any other suggestions?

i'll tell you how this churned out after you inputs.

to note, changes have been made to case to keep case unindentifiable and confidential

Need more info man... VS? Are we talking fall from 4ft or 40ft? You mentioned a CXR that shows pneumonia vs edema vs blood? If I'm suspicious of a HTX, then my approach is going to be significantly different. If we're talking about a fall from standing where she whacked her head but you're telling me she's GCS 15 with nothing more than mild tachypnea, I'd first check the sat probe. If I had edema vs pneumonia and 86% on 15L, I'd probably be slightly more than mildly tachypneic. If I'm not strongly suspicious of intrathoracic trauma and you think this is resp distress 2/2 volume overload or pneumonia, then... what's the rush? You've got time to get everything set up properly, so no reason to paralyze this fat chick and watch her sats drop faster than the Dow Jones on Black Monday. I'd put her on Bipap while I get everything set up, expecting her to fail the Bipap trial but at least be moderately improved from where I started while I get my gear set up. I'm not a fan of Etomidate alone with no paralytics. This girl probably had a big mac for lunch 20 mins ago and the last thing I need is her aspirating pickles and mustard while I peek around inside her fat neck. If I'm going to tube her, I'm going to give myself the best chance possible...without knocking her out till Sunday.. propofol and vec, (mivacron if you've got it) would be my choice in this case. I'd like a mac 4, miller 2, 8.0 and 7.5 ETT, glidescope set up and ready, LMA, and bougie with cric tray in the general vicinity. If I had a bronchoscope nearby, I'd prefer that.

If she doesn't pass Bipap trial, then she buys the tube. Direct laryngoscopy with head of bed elevated, in line traction on neck by assistant, bougie, ETT over bougie, LMA if no luck, bag her up as good as possible and try with glidescope.

OR, if I've got a bronch handy... I'd prob try to get creative and pass the bronch through the LMA and feed the ETT over that. Be sure to cut the aperture bars off the LMA so you have the option of feeding bougie/bronch/ETT down it. I have a hard time believing I'd fail in all of those approaches but you didn't tell us what gear you had available.

Technically, I'd prob have the best first chance at success with a glidescope, with a standby bougie assisted approach visualized with the monitor in case I couldn't make it with the rigid stylet.

Xaelia, nice idea bout the bougie through the LMA. I've read some good articles on that.

 

[BF2BC EMT]

thanks so far for the replies. i'd be happy to keep hearing others feedback/input.

i opted to use only etomidate with use of glidescope.

i went this route because in the past i had a similar case where after inducing and paralyzing a similar patient, the already low 02 sats plummeted and the patient proofed difficult to bag and intubate. in that case, i ended up using an LMA.

for this case, things started well, patient was nice and sedated after etomidate, able to see cords with glidescope, passed et tube, but then the patient was impossible to bag. it was like pressing your hand through a rock when trying to bag. turns out, the patient appears to have had a masseter spasm and was clenched down on the et tube.

placed nasal trumpet bilaterally, gave rocuronium, teased the et tube out, bagged through the nasal trumpets, was then able to re-intubate again with glidescope.

I'm thinking of maybe using versed without paralytic next time instead of etomidate without paralytic in similar case. turns out there are documented cases of masseter spasm with etomidate.

anyone else?

With the versed, was the pt post dialysis(hypotensive)?

 

[WilcoWorld]

... but then the patient was impossible to bag. it was like pressing your hand through a rock when trying to bag. turns out, the patient appears to have had a masseter spasm and was clenched down on the et tube.

This is why I don't like to attempt intubation without paralytics - I find that there is all-too-often inadequate muscular relaxation and that this leads to a much higher rate of complications. In this patient I would
a) optimize positioning before giving any meds (get an airway ramp or a stack of blankets behind the patient BEFORE giving meds)
b) get my laryngyscope and bougie ready with an LMSA handy as well
c) have a provider ready to do a cric at the bedside
d) push paralytics (roc) and then sedative (yes in that order, by the time the Roc takes effect the sedative will be taking effect as well, and with this approach I'll be ready to take a look about 45 seconds earlier, which can make a difference in a hypoxic patient (and I'll always make sure we have 2 patent IVs before pushing a paralytic))
e) quickly take my look
e1) If I have a great view on 1st pass - the ETT goes in
e2) If I have only a partial view, I'll go straight to bougie on that 1st try and tube over the bougie
e3) If I can't get a good view right away I'll place an LMA supreme (which I can use to ventilate/place an OG through to empty the stomach/convert to ETT once I've better stabilized the patient's physiology)

 

[southerndoc]

Mallampati may not be the the best to decide who is difficult to intubate, but it is a gauge that one can easily communicate over a discussion forum to give us a better sense of what the airway looks like pre-intubation instead of just describing a short neck and obese patient. I've seen some obese short-necked patients have Mallampati's of 1 that were easy intubations.

 

[Rendar5]

Haven't looked down yet to see what was done or suggested. first thought is that there is already a very large shunt going on. If you think this is more sympathetic mediated pulmonary edema (high BP, no fever, b/l rales), then trial of bipap with nitro.

But if that's not the picture, I'd induce with etomidate and roc or ketamine with roc and LMA this person. If I have an intubating LMA on hand all the better. But if it's a standard LMA, I would oxygenate them and then swap over to a tube.

 

[Rendar5]

thanks so far for the replies. i'd be happy to keep hearing others feedback/input.

i opted to use only etomidate with use of glidescope.

i went this route because in the past i had a similar case where after inducing and paralyzing a similar patient, the already low 02 sats plummeted and the patient proofed difficult to bag and intubate. in that case, i ended up using an LMA.

for this case, things started well, patient was nice and sedated after etomidate, able to see cords with glidescope, passed et tube, but then the patient was impossible to bag. it was like pressing your hand through a rock when trying to bag. turns out, the patient appears to have had a masseter spasm and was clenched down on the et tube.

placed nasal trumpet bilaterally, gave rocuronium, teased the et tube out, bagged through the nasal trumpets, was then able to re-intubate again with glidescope.

I'm thinking of maybe using versed without paralytic next time instead of etomidate without paralytic in similar case. turns out there are documented cases of masseter spasm with etomidate.

anyone else?

Ok, so you did good in your response to when things whent bad. I may have tested the ETT after the spasm ended to see if there was any airleak, and if so I just would've let anaesthesia do a tube change if they're around (they have a nice tube exchanger) if they were around. Otherwise I'd do it myself over a bougie.

But as said above, you're more likely to avoid this by using paralytics. I appreciate your concern for the super-fast sat drop, but that's what LMA is for or bipap prior to intubation. both in essence pre-oxygenate for the actual look-around with your blade or scope.

 

[pgg]

for this case, things started well, patient was nice and sedated after etomidate, able to see cords with glidescope, passed et tube, but then the patient was impossible to bag. it was like pressing your hand through a rock when trying to bag. turns out, the patient appears to have had a masseter spasm and was clenched down on the et tube.

Light patient biting the tube != masseter spasm

Happens a lot when patients are light. Next time consider putting in a bite block right after the tube goes in. Also, muscle relaxant instead of extubation might have been a better option. Bronchospasm may have been part of the problem (again perhaps pointing at a light patient).


This can be quite dangerous and result in negative pressure pulmonary edema if the patient makes a sufficiently forceful inspiratory effort through a blocked ETT. Admittedly unlikely in a 60+ yo female - the classic NPPE patient is a young healthy patient emerging from anesthesia. Don't let patients bite tubes, ever.

Ok, so you did good in your response to when things whent bad. I may have tested the ETT after the spasm ended to see if there was any airleak, and if so I just would've let anaesthesia do a tube change if they're around (they have a nice tube exchanger) if they were around. Otherwise I'd do it myself over a bougie.

Why exchange a perfectly good tube? Either it's in the trachea or not. Biting down on it won't damage it.

 

[Flopotomist]

What about giving a little nebulized lidocaine and then trying an awake Nasotracheal over a scope?

 

[Rendar5]

Why exchange a perfectly good tube? Either it's in the trachea or not. Biting down on it won't damage it.

I had assumed the OP had taken the tube out because he was concerned about a massive bite damaging the cuff mechanism (I've seen this happen once, it was very strange). Thus, saying to test for air leak before even considering exchanging a perfectly good tube. Now I realize that he likely took the tube out because he coudlnt' bag around it . In this case I may have just deflated the cuff to allow for better bagging, since it shouldn't take long at all for a push of sedation or muscle relaxation to kick in.

 

[FDNewbie]

Just FYI, it's T-burg (or Trendelenburg). And Trendelenburg position is feet higher than head. Reverse Trendelenburg is head higher than feet.

You're absolutely right. Thanks for correcting my brain fart

Mallampati may not be the the best to decide who is difficult to intubate, but it is a gauge that one can easily communicate over a discussion forum to give us a better sense of what the airway looks like pre-intubation instead of just describing a short neck and obese patient. I've seen some obese short-necked patients have Mallampati's of 1 that were easy intubations.

Fair enough.

From a practical standpoint, do you ever really obtain a Mallampati on your patients in the ED? Cuz typically if I'm tubing someone, it's not elective in any form or fashion, ie they WILL REQUIRE intubation, no questions asked - and usually NOW. So I don't have many alternatives. We're doin it, we're doin it. I simply prepare for each intubation as if it's a difficult one. I'll eyeball the patient to get an idea of how bad I think it may be, but I don't really do the whole going through all the motions (Mallampati, fingers under the chin, etc.). Do you guys go through 'em routinely?

for this case, things started well, patient was nice and sedated after etomidate, able to see cords with glidescope, passed et tube, but then the patient was impossible to bag. it was like pressing your hand through a rock when trying to bag. turns out, the patient appears to have had a masseter spasm and was clenched down on the et tube.

placed nasal trumpet bilaterally, gave rocuronium, teased the et tube out, bagged through the nasal trumpets, was then able to re-intubate again with glidescope

I understand everyone's got their different perspective, but if you confirmed the ETT was in place via direct visualization, and are sure it went in the trachea, I'd NEVER take that back out. You can trouble shoot via several other ways without potentially losing an airway that you were obviously working hard to secure in the first place.

If you were concerned about the tube being damaged as mentioned elsewhere, I woulda changed the tube out over a bougie to maintain placement of the airway. Definitely wouldn't take the tube out completely and start at the beginning ALL over again...

Also, FYI, once you've secured the airway, if the patient is bucking the vent, biting the tube, etc. again, as others mentioned, a bite block is an EXCELLENT option. And if all else fails, and sedation isn't doing it for you either, that's an indication for paralysis. So NOW you can use your succs or vec, etc. Still wouldn't take the tube out. But again, that's just me.

c) have a provider ready to do a cric at the bedside

1) I'm a firm believer that the ED Physician should be very verse & comfortable performing the cric. At a lot of facilities, you are the ONLY physician available, and being uncomfortable with obtaining a definitive airway anywhere along the spectrum of what it takes isn't such a hot idea IMO.

2) Having said that, I think ppl jump to a cric WAYY too early/unnecessarily. The ONLY true indication that I can think of is inability to bag a patient at all and/or maintain adequate SaO2. As long as you can bag the patient and the SaO2 is ok, you're ok, and can continue additional/alternative methods at your leisure. There's no emergency to cause significant & poss. permanent damage to the patient via a cric. Granted, there are rare cases where a definitive airway may be absolutely required, but even then, you can buy time with an LMA or other device instead of cutting someone's neck open. And this is coming from someone who's not scalpel-shy either lol.

 

[pinipig523]

Read the OP's post real quick:

2 ways about this:

1. Induce w/o paralysis
- If I do this, I'm going to go with the sure thing - glidescope.
- I have done this before and I can see the cords, then paralyze to open the cords - tube.

2. Probably the better method, induce AND paralyze
- No sux
- Use etomidate 30mg iv x1, then max out the Roc to perhaps 75mg iv x1.
- Bougie on hand, bent 60 degrees at the neck to improve epiglottis riding ability
- Miller instead of MAC
- Glidescope if possible at bedside (and if this is around, I'd use it FIRST before I lose vision to possibly gastric contents or blood)
- Anesthesia on standby is not possible - they would never let me intubate without them intubating. There is NO such thing as anesthesia on standby from my experience. If you call them, they intubate - not you.

 

[southerndoc]

From a practical standpoint, do you ever really obtain a Mallampati on your patients in the ED? Cuz typically if I'm tubing someone, it's not elective in any form or fashion, ie they WILL REQUIRE intubation, no questions asked - and usually NOW. So I don't have many alternatives. We're doin it, we're doin it. I simply prepare for each intubation as if it's a difficult one. I'll eyeball the patient to get an idea of how bad I think it may be, but I don't really do the whole going through all the motions (Mallampati, fingers under the chin, etc.). Do you guys go through 'em routinely?

It's a Joint Commission requirement to document Mallampatis on your procedural sedation patients. We usually document it on both procedural sedation and intubations (if the patient was awake prior to intubation).

 

[FDNewbie]

It's a Joint Commission requirement to document Mallampatis on your procedural sedation patients. We usually document it on both procedural sedation and intubations (if the patient was awake prior to intubation).

Yea I'm with ya re: the procedural sedations, because you have the time. Don't really do it in the urgent/emergent ones. I guess it's good practice, given the possible complications...ie your documentation shows you did your job. Good point. Thanks.

 

[WilcoWorld]

1) I'm a firm believer that the ED Physician should be very verse & comfortable performing the cric. At a lot of facilities, you are the ONLY physician available, and being uncomfortable with obtaining a definitive airway anywhere along the spectrum of what it takes isn't such a hot idea IMO.

2) Having said that, I think ppl jump to a cric WAYY too early/unnecessarily. The ONLY true indication that I can think of is inability to bag a patient at all and/or maintain adequate SaO2. As long as you can bag the patient and the SaO2 is ok, you're ok, and can continue additional/alternative methods at your leisure. There's no emergency to cause significant & poss. permanent damage to the patient via a cric. Granted, there are rare cases where a definitive airway may be absolutely required, but even then, you can buy time with an LMA or other device instead of cutting someone's neck open. And this is coming from someone who's not scalpel-shy either lol.

In 6+ years of intubating I have had to go to cric exactly once. It is not something I jump to readily. However, the patient you described is the kind who will go into a hypoxic bradycardic arrest if you take too many "looks" as their sats drop from 86 to 70 to 60 to... That's why I'm preparing for that alternative in my pre-game.
Also, it's not due to an inability to cric that I said I'd want someone ready at the bedside. I work in an academic center, so there is always another doc around. If someone is standing there with beta dine and a blade, things will go more quickly than they would if the intubater has to switch modes & set-up after failing to get the tube in.

You asked what different poster's approaches would be - given my situation, mine would be to have someone ready to cric at the bedside even though they very rarely end up having to do so.

 

[Tiger26]

This is why I don't like to attempt intubation without paralytics - I find that there is all-too-often inadequate muscular relaxation and that this leads to a much higher rate of complications. In this patient I would
a) optimize positioning before giving any meds (get an airway ramp or a stack of blankets behind the patient BEFORE giving meds)
b) get my laryngyscope and bougie ready with an LMSA handy as well
c) have a provider ready to do a cric at the bedside
d) push paralytics (roc) and then sedative (yes in that order, by the time the Roc takes effect the sedative will be taking effect as well, and with this approach I'll be ready to take a look about 45 seconds earlier, which can make a difference in a hypoxic patient (and I'll always make sure we have 2 patent IVs before pushing a paralytic))
e) quickly take my look
e1) If I have a great view on 1st pass - the ETT goes in
e2) If I have only a partial view, I'll go straight to bougie on that 1st try and tube over the bougie
e3) If I can't get a good view right away I'll place an LMA supreme (which I can use to ventilate/place an OG through to empty the stomach/convert to ETT once I've better stabilized the patient's physiology)

I'd take Wilco's approach. Overall, the last thing I'd use for an awake look would be etomidate given at least 20% chance of muscle spasm.

I'd go a generous dose of Rocc (1.2 per total, not ideal, body weight)-->induction agent-->tube first with glidescope in this case.

Regarding xaelia's question about the ILMA, it's very difficult to be successful with a bougie through as a guide, but not impossible. As an alternative, I'd recommend putting a non-styleted ET tube in so that the curve of the ET tube is opposite the curve of the LMA. It seems somewhat contradictory, but open one up sometime, and you'll see doing so will direct it nicely to where you want to go.

 

[FDNewbie]

In 6+ years of intubating I have had to go to cric exactly once. It is not something I jump to readily. However, the patient you described is the kind who will go into a hypoxic bradycardic arrest if you take too many "looks" as their sats drop from 86 to 70 to 60 to... That's why I'm preparing for that alternative in my pre-game.

Fair enough. But plz don't think I was jumping on you with my post. Merely commenting on the topic mentioned (cric) cuz I've seen some ppl who are wayyy too quick to wanna jump to that step - and it isn't to be taken lightly.

Also, it's not due to an inability to cric that I said I'd want someone ready at the bedside. I work in an academic center, so there is always another doc around. If someone is standing there with beta dine and a blade, things will go more quickly than they would if the intubater has to switch modes & set-up after failing to get the tube in.

Gotcha. By set up, are you referring to the cric by Seldinger technique via a needle & guidewire etc? When push comes to shove, and I actually need a cric, I'm a fan of an open technique. Quick 'n dirty, but very effective. Cut #1 = skin down to trachea. Slice # 2 = open trachea. Insert ETT, while someone obtains a trach for insertion instead. There's a QuickTrach kit I've been playing with for a bit now, but have had difficulty getting it to work as quickly and easily as I'd like it to...

You asked what different poster's approaches would be - given my situation, mine would be to have someone ready to cric at the bedside even though they very rarely end up having to do so.

Gotcha. And I'm all ears. Wasn't trying to be critical at all. Hard to tell tone with just text

 

[WilcoWorld]

Fair enough. But plz don't think I was jumping on you with my post. Merely commenting on the topic mentioned (cric) cuz I've seen some ppl who are wayyy too quick to wanna jump to that step - and it isn't to be taken lightly.

Gotcha. By set up, are you referring to the cric by Seldinger technique via a needle & guidewire etc? When push comes to shove, and I actually need a cric, I'm a fan of an open technique. Quick 'n dirty, but very effective. Cut #1 = skin down to trachea. Slice # 2 = open trachea. Insert ETT, while someone obtains a trach for insertion instead. There's a QuickTrach kit I've been playing with for a bit now, but have had difficulty getting it to work as quickly and easily as I'd like it to...

Gotcha. And I'm all ears. Wasn't trying to be critical at all. Hard to tell tone with just text

Sounds like we're on the same page here, just lacking the benefit of non-textual cues to flesh out the meaning.

 

[cincincyreds]

Here is the answer to your question. First, get help from an Anesthesiologist in your hospital before proceeding. This is a situation that can turn real bad real quick. In fact, I had to run down to the ER a few weeks ago in a similar situation with a sat of 50% after an ER doc felt like he was going to be the hero. Luckily, I placed a bougie blindly as I didn't have much time and passed a tube over it. The airway was so bloody for some reason, probably from the INR of 6 from Coumadin, I couldn't see anything with DL.

What I would do is start a precedex infusion, but no bolus. This should provide sedation and also help with pain. Then, I would topicalize the patient's airway with lidocaine. At the same time I would be providing oxygen to the patient to get the sat above 90%. If it appears really dire, I would have ENT in the room ready for a surgical airway. If it appears after topicalization the O2 sat is reasonable, I either grab a glidescope and take an awake look or do a fiberoptic intubation with the patient awake, topicalizated, sedated, breathing spontaneously. This way, no bridges are burned.

Once you paralyze that patient, you may only have 30 seconds to a minute before you need a lawyer if you can't intubate or ventilate that patient. Also, the potassium may be really high, and if you are talking about a RSI with Sux, you may need another lawyer after the hyperkalemic arrest.

So in closing, don't be hero. Don't be afraid to ask for help. I don't mind helping out, in fact, it is my pleasure. But I prefer a situation where bridges haven't been burned yet.

 

[deleted109597]

So in closing, don't be hero. Don't be afraid to ask for help. I don't mind helping out, in fact, it is my pleasure. But I prefer a situation where bridges haven't been burned yet.

Sure. Tell you what. You and the ENT stay in house at the 3 hospitals I work at where I'm the only doc in the building, and I'll be happy to call you for all airways, as they all have the potential to go bad.

Yes, we should all know what our limitations are. However, sometimes the second pair of hands is never there. The other day I had to go upstairs to rescue the RTs, as the admitting MD, over the phone, gave an order "OK to intubate" on a head bleed that had recently come out of the ICU. I was called because the RTs can't give paralytics, and this guy was biting them as they tried to intubate, yet still not protecting. I had never seen this degree of mouth rape. Blood everywhere. He was bradying down when I walked in the room. Not an ideal situation, and certainly not one that could be fixed by someone driving in from home after answering their pager.

 

[txterp98]

Cincincyreds, your point about proper preparation and having the most experienced operator make the first attempt is valid. Your assumption that an anesthesiologist and ENT surgeon are readily available, though, is not.

3 of the sites I will occasionally work at:
1) Burleson St. Joseph - Caldwell, TX - ER Beds: 3, Hospital Beds: 25
2) Seton Edgar B Davis - Luling, TX - ER Beds: 4, Hospital Beds: 25
3) Seton Highland Lakes - Burnet, TX - ER Beds: 8, Hospital Beds: 42

You genuinely believe an anesthesiologist is present around-the-clock? And an ENT surgeon? Really?

In addition, you think the hospital stocks Precedex?

Again, you are absolutely correct about proper preparation and maximizing first-pass success with the most experienced physician making the initial attempt. That should not detract, though, from the spirit of this discussion. Frankly, at many sites across the US, the physician in the ER better have thought about these scenarios prior to it becoming reality.

McNinja - couldn't agree with your post more, bud.

 

[Hamhock]

Here is the answer to your question. First, get help from an Anesthesiologist in your hospital before proceeding. This is a situation that can turn real bad real quick. In fact, I had to run down to the ER a few weeks ago in a similar situation with a sat of 50% after an ER doc felt like he was going to be the hero. Luckily, I placed a bougie blindly as I didn't have much time and passed a tube over it. The airway was so bloody for some reason, probably from the INR of 6 from Coumadin, I couldn't see anything with DL.

What I would do is start a precedex infusion, but no bolus. This should provide sedation and also help with pain. Then, I would topicalize the patient's airway with lidocaine. At the same time I would be providing oxygen to the patient to get the sat above 90%. If it appears really dire, I would have ENT in the room ready for a surgical airway. If it appears after topicalization the O2 sat is reasonable, I either grab a glidescope and take an awake look or do a fiberoptic intubation with the patient awake, topicalizated, sedated, breathing spontaneously. This way, no bridges are burned.

Once you paralyze that patient, you may only have 30 seconds to a minute before you need a lawyer if you can't intubate or ventilate that patient. Also, the potassium may be really high, and if you are talking about a RSI with Sux, you may need another lawyer after the hyperkalemic arrest.

So in closing, don't be hero. Don't be afraid to ask for help. I don't mind helping out, in fact, it is my pleasure. But I prefer a situation where bridges haven't been burned yet.

Replace 'precedex' with 'ketamine' and I think this is what is I would try...and the addition of BiPap (not CPAP) to pre-oxygenate and get the pH up...place a nasal cannula with a high flow rate as soon as I remove the BiPap for intubation...Glidescope view before NBM...if great view and little resistence, then tube +/- roc...o/w, bougie then roc and tube

HH

 

[FDNewbie]

Here is the answer to your question. First, get help from an Anesthesiologist in your hospital before proceeding. This is a situation that can turn real bad real quick. In fact, I had to run down to the ER a few weeks ago in a similar situation with a sat of 50% after an ER doc felt like he was going to be the hero. Luckily, I placed a bougie blindly as I didn't have much time and passed a tube over it. The airway was so bloody for some reason, probably from the INR of 6 from Coumadin, I couldn't see anything with DL.

What I would do is start a precedex infusion, but no bolus. This should provide sedation and also help with pain. Then, I would topicalize the patient's airway with lidocaine. At the same time I would be providing oxygen to the patient to get the sat above 90%. If it appears really dire, I would have ENT in the room ready for a surgical airway. If it appears after topicalization the O2 sat is reasonable, I either grab a glidescope and take an awake look or do a fiberoptic intubation with the patient awake, topicalizated, sedated, breathing spontaneously. This way, no bridges are burned.

Once you paralyze that patient, you may only have 30 seconds to a minute before you need a lawyer if you can't intubate or ventilate that patient. Also, the potassium may be really high, and if you are talking about a RSI with Sux, you may need another lawyer after the hyperkalemic arrest.

So in closing, don't be hero. Don't be afraid to ask for help. I don't mind helping out, in fact, it is my pleasure. But I prefer a situation where bridges haven't been burned yet.

Awake intubation?? Are you an anesthesiologist? If I tried an "awake" intubation in HALF my patients, they would DIE before I even had the awake/difficult intubation cart down here from Anesthesia. These patients come in TANKING, often after getting solumedrol, mult nebs, CPAP, the whole 9, and NOTHING is working, and sats are in the tanker as EMS brings 'em in the ED. And the guy's huffin & puffin so bad, he's only got a few more minutes goin before he'll get so hypoxic, go into respiratory failure, and brady arrest.

And again, as someone else mentioned, Precedex? And you're gonna get that from where? Pharmacy 20 minutes later? After they fight you for 15 of those minutes why it's not indicated in any circumstance in the ED?

Lastly, as mentioned earlier, you find me an ENT willing to come in to intubate at 3AM, and I'll work on finding a patient who can hold on for those 25 minutes with dismal sats in extremis while the ENT makes it to the ED.

 

[Rendar5]

Awake intubation?? Are you an anesthesiologist? If I tried an "awake" intubation in HALF my patients, they would DIE before I even had the awake/difficult intubation cart down here from Anesthesia. These patients come in TANKING, often after getting solumedrol, mult nebs, CPAP, the whole 9, and NOTHING is working, and sats are in the tanker as EMS brings 'em in the ED. And the guy's huffin & puffin so bad, he's only got a few more minutes goin before he'll get so hypoxic, go into respiratory failure, and brady arrest.

And again, as someone else mentioned, Precedex? And you're gonna get that from where? Pharmacy 20 minutes later? After they fight you for 15 of those minutes why it's not indicated in any circumstance in the ED?

Lastly, as mentioned earlier, you find me an ENT willing to come in to intubate at 3AM, and I'll work on finding a patient who can hold on for those 25 minutes with dismal sats in extremis while the ENT makes it to the ED.

yes, he's an anaesthesiologist and doesn't generally deal with intubations in our world, but that doesn't mean we should dismiss his suggestions, or avoid calling him in certain more stable situations if you happen to be in an academic center.

if you have precedex available, and some ERs do, it's a good alternative to ketamine for preoxygenation if the guy's gonna be fighting you on bipap. awake intubation is something that ED docs should be aware of for some situations (obese person with angioedema, e.g.). If you want some good demonstrations of it from an EM guy, check out emcrit.org.

 

[Hamhock]

Awake intubation?? Are you an anesthesiologist? If I tried an "awake" intubation in HALF my patients, they would DIE before I even had the awake/difficult intubation cart down here from Anesthesia. These patients come in TANKING, often after getting solumedrol, mult nebs, CPAP, the whole 9, and NOTHING is working, and sats are in the tanker as EMS brings 'em in the ED. And the guy's huffin & puffin so bad, he's only got a few more minutes goin before he'll get so hypoxic, go into respiratory failure, and brady arrest.

And again, as someone else mentioned, Precedex? And you're gonna get that from where? Pharmacy 20 minutes later? After they fight you for 15 of those minutes why it's not indicated in any circumstance in the ED?

Lastly, as mentioned earlier, you find me an ENT willing to come in to intubate at 3AM, and I'll work on finding a patient who can hold on for those 25 minutes with dismal sats in extremis while the ENT makes it to the ED.

Agree with Rendar5: Awake intubation (using a Glidescope) is not that far of a stretch for many EM docs.

Regarding fighting with pharmacy for Precedex: see my post above. Use ketamine.

I would suggest re-directing some of that energy in your post away from the anesthesiologist, who is providing a different and useful perspective, and towards re-structuring your ED so that you don't have to wait for the "awake/difficulty airway" cart to "come down from Anesthesia". It should already be in the ED.

HH

 

[KYTNOH]

Here is the answer to your question. First, get help from an Anesthesiologist in your hospital before proceeding. This is a situation that can turn real bad real quick. In fact, I had to run down to the ER a few weeks ago in a similar situation with a sat of 50% after an ER doc felt like he was going to be the hero. Luckily, I placed a bougie blindly as I didn't have much time and passed a tube over it. The airway was so bloody for some reason, probably from the INR of 6 from Coumadin, I couldn't see anything with DL.

What I would do is start a precedex infusion, but no bolus. This should provide sedation and also help with pain. Then, I would topicalize the patient's airway with lidocaine. At the same time I would be providing oxygen to the patient to get the sat above 90%. If it appears really dire, I would have ENT in the room ready for a surgical airway. If it appears after topicalization the O2 sat is reasonable, I either grab a glidescope and take an awake look or do a fiberoptic intubation with the patient awake, topicalizated, sedated, breathing spontaneously. This way, no bridges are burned.

Once you paralyze that patient, you may only have 30 seconds to a minute before you need a lawyer if you can't intubate or ventilate that patient. Also, the potassium may be really high, and if you are talking about a RSI with Sux, you may need another lawyer after the hyperkalemic arrest.

So in closing, don't be hero. Don't be afraid to ask for help. I don't mind helping out, in fact, it is my pleasure. But I prefer a situation where bridges haven't been burned yet.

I'm sorry, but this just isn't realistic in 95% of the hospitals in the US. It's easy for anesthesia to criticize when their intubations are on patients NPO for 12 hours, in an OR, with perfect positioning and time to prepare for everything. Anesthesia intuations = perfect scenario. ED intubations = imperfect scenario. Outside of academic centers and large tertiary care centers, anesthesia isn't in house. I would estimate that 75% of hospitals in the US don't have any ENT coverage, and when they do it's going to take at least 30 minutes to get them in house.

Also, if this was a fall from standing, I would ignore the trauma issue for the immediate resuscitation. It sure sounds like pulmonary edema, and a fall from standing is unlikely to cause injuries that can't be put off for 20 or 30 minutes (I'm not saying 0% chance, but very remote chance). I would jetison the Cervical Collar because in this patient the odds of it being beneficial are remote at best, and the odds of it worsening the airway and breathing assessment and management are significant. Secondly, if a CXR could be obtained to assess the patient then a trial of BiPAP could also probably be made to see if it can improve oxygenation.

If BiPAP doesn't work then I think there are multiple options. In my opinion, with difficult airways there is no 100% correct algorithm as it depends entirely on the hospitals capabilities and user experience. You could have a brand new Glidescope, but if someone hasn't used it in the past on relatively stable patients then a crashing patient is not the time to count on it as backup. You could be proficient at fiberoptic intubations, but if you're moonlighting in a small hospital with no fiberoptic equipment then its not an option.

I'm personally conflicted on whether to use paralytics in these patients or not. There were anesthesia studies in the late 80s that randomized patients to either paralytics or no paralytics and the study was stopped prematurely because the outcomes were so much better for the paralytic group. So you're faced with the option of an awake intubation that has a higher failure rate than true RSI versus a true RSI that will have a much higher initial success rate but with a very small chance of a failed airway with iatrogenic apnea. I honestly don't know what's worse. The one caveat would be that those studies were done with direct laryngoscopy only. With the advent of video assisted intubations those outcomes might be significantly different.

 

[deleted109597]

The awake vs not awake or paralyzed vs non-paralyzed discussion seems to happen a lot. My take is that no intubations in the ED are elective. Thus, they're being tubed because they aren't doing the breathing thing very well. So to me, I have an much better chance of intubating a paralyzed patient over one that isn't. BiPAP™ would be nearly equivalent to bagging, and if they can't bag, they can't BiPAP™, awake or not.
Thus, I would ketamine/roc, and have advanced equipment at bedside.

 

[Cerberus]

The awake vs not awake or paralyzed vs non-paralyzed discussion seems to happen a lot. My take is that no intubations in the ED are elective. Thus, they're being tubed because they aren't doing the breathing thing very well. So to me, I have an much better chance of intubating a paralyzed patient over one that isn't. BiPAP™ would be nearly equivalent to bagging, and if they can't bag, they can't BiPAP™, awake or not.
Thus, I would ketamine/roc, and have advanced equipment at bedside.

I have yet to see an intubation in the ED without a paralytic go smoothly. Given it's rare that we intubate without paralytics here (I did a few weeks ago on a crashing pt with no line, and the end result was them biting down so that I couldn't pass the tube until at the last minute my co-resident got femoral access and pushed roc). I have yet to see a case where I wouldn't paralyze before sedating. I'll bag if I have to, and if I can't bag and can't intubate, I'll cric (a rarer combo in my experience than having a pt who is anything but a disaster when you attempt to crash intubate without paralytics on board).

 

[southerndoc]

It amazes me how defensive some ED physicians get when another specialist tries to give us tips. We're not the specialists of airways. Yes, we're skilled in emergent airways, but the anesthesiologists do this every day. They've had way more experience than us.

Two days ago I had a difficult airway that me and a pulmonologist couldn't get even with a GlideScope because the guy was so obese, no neck, and very anterior. The anesthesiologist came down and said it was all about preparation. He joked that when a patient doesn't have a neck, you have to create one for him. He repositioned the patient, gave us a few tips, and put the tube in with a GlideScope with only a moderate amount of difficulty. Had we done that we could've tubed the guy without calling him.

I didn't get defensive. I recognized he has more experience in airways than I do, and I learned from the experience.

If an anesthesiologist, cardiologist, surgeon, or whatever gives you tips, don't get defensive about it. We spent part of 3-4 years of training doing airways. They spend their entire training doing airways and inductions.

 

[Cerberus]

It amazes me how defensive some ED physicians get when another specialist tries to give us tips. We're not the specialists of airways. Yes, we're skilled in emergent airways, but the anesthesiologists do this every day. They've had way more experience than us.

Two days ago I had a difficult airway that me and a pulmonologist couldn't get even with a GlideScope because the guy was so obese, no neck, and very anterior. The anesthesiologist came down and said it was all about preparation. He joked that when a patient doesn't have a neck, you have to create one for him. He repositioned the patient, gave us a few tips, and put the tube in with a GlideScope with only a moderate amount of difficulty. Had we done that we could've tubed the guy without calling him.

I didn't get defensive. I recognized he has more experience in airways than I do, and I learned from the experience.

If an anesthesiologist, cardiologist, surgeon, or whatever gives you tips, don't get defensive about it. We spent part of 3-4 years of training doing airways. They spend their entire training doing airways and inductions.

True, but I don't think we should always take their word as gospel. They generally see a different type of patient then we do in a different setting than we do. Hell, I had a cardiologist trying to put a pacer in my dig toxic pt the other day before they even received digibind (while mentating fine).

 

[Painter1]

It amazes me how defensive some ED physicians get when another specialist tries to give us tips. We're not the specialists of airways. Yes, we're skilled in emergent airways, but the anesthesiologists do this every day. They've had way more experience than us.

Two days ago I had a difficult airway that me and a pulmonologist couldn't get even with a GlideScope because the guy was so obese, no neck, and very anterior. The anesthesiologist came down and said it was all about preparation. He joked that when a patient doesn't have a neck, you have to create one for him. He repositioned the patient, gave us a few tips, and put the tube in with a GlideScope with only a moderate amount of difficulty. Had we done that we could've tubed the guy without calling him.

I didn't get defensive. I recognized he has more experience in airways than I do, and I learned from the experience.

If an anesthesiologist, cardiologist, surgeon, or whatever gives you tips, don't get defensive about it. We spent part of 3-4 years of training doing airways. They spend their entire training doing airways and inductions.

how did he position the patient? shoulder rolls?

 

[deleted109597]

It amazes me how defensive some ED physicians get when another specialist tries to give us tips. We're not the specialists of airways. Yes, we're skilled in emergent airways, but the anesthesiologists do this every day. They've had way more experience than us.

I don't think any of us were defensive about the advice for sedation/anesthetic. It's the "call the anesthesiologist immediately" part that many of us (myself included) thought ludicrous.

 

[FDNewbie]

I'll echo what was said above. It's not that I'm unwilling to learn from the experts in their field. In fact, that's my preference. Sure EM gave me a ton of training, but I still specifically sought out airway from Anesthesia, chest tubes from CT surgeons, etc. Getting it from the specialists is definitely an advantage.

BUT, you also have to realize that their advice & technique is constrained by circumstance & available resources. As mentioned above, we don't often have the opportunity to go through a difficult intubation algorithm from start to finish (which, ends in "if all else fails, cancel the OR case, FYI). I don't have that luxury. If I'm gonna tube someone, 9/10 it's because it's urgent & emergent/life threatening. 1/10 times its not so urgent. Sure, can I take additional steps to prepare beforehand? For the most part. But some suggestions can be quite out of place, no matter how well-meant they are. Recognizing the unique environment in the ED is key.

Having said that, I'll be the first to say that YMMV (your mileage may vary). I'm sure there are some times where Anesthesia feels they're saving patient after patient from poorly trained EM docs, and rightfully so. But there are also many times where EM docs have tons of experience in a COMPLETELY different airway setting (crash airways; not controlled airways as is the norm in Anesthesia), and if the EM doc isn't gonna get it, Anesthesia's gonna be hard pressed to get it. And EM earns its respect for it's unique challenges, environment, and constraints from Anesthesia because of it.

 

[Arch Guillotti]

BUT, you also have to realize that their advice & technique is constrained by circumstance & available resources. As mentioned above, we don't often have the opportunity to go through a difficult intubation algorithm from start to finish (which, ends in "if all else fails, cancel the OR case, FYI).

Friend this statement is not really accurate at all.

Very rarely in the OR we go down the can't ventilate/can't intubate scenario. If all else fails for an elective case, you do wake the patient up. This has never happened to me in my short career. You don't necessarily cancel the case though. I know of instances where the patient has woken up and the operation has proceeded after an awake fiberoptic intubation.

We see a good amount of cases where waking up is not an option and we must proceed as needed down the algorithm without turning back. Trauma patients do not get woken up for a do-over or cancellation. Neither do the cases that come up to the OR for airway control (angioedema, pending airway obstruction from tumor, patient in respiratory distress).

Most of our cases are elective and we have the luxury of advance preparation that is not possible in the ED. This is not always the case though.

 

[Arcan57]

I'll echo what was said above. It's not that I'm unwilling to learn from the experts in their field. In fact, that's my preference. Sure EM gave me a ton of training, but I still specifically sought out airway from Anesthesia, chest tubes from CT surgeons, etc. Getting it from the specialists is definitely an advantage.

BUT, you also have to realize that their advice & technique is constrained by circumstance & available resources. As mentioned above, we don't often have the opportunity to go through a difficult intubation algorithm from start to finish (which, ends in "if all else fails, cancel the OR case, FYI). I don't have that luxury. If I'm gonna tube someone, 9/10 it's because it's urgent & emergent/life threatening. 1/10 times its not so urgent. Sure, can I take additional steps to prepare beforehand? For the most part. But some suggestions can be quite out of place, no matter how well-meant they are. Recognizing the unique environment in the ED is key.

I'm not really sure why you wouldn't have the ability to go through a difficult airway algorithm in the ED. The modalities may change slightly depending on user proficiency, but the stops along the way stay relatively constant. If your ED doesn't have a Bougie, or a Glidescope, or LMAs then either bring them with you on a shift (easier for the 1st and 3rd option) or get the hospital to pony up. As ED docs, most of us expect to be successful with our first modality (either DL or Glidescope). And the data shows we usually are. That's not an excuse for not having a rigorously thought out plan for what to do when things go sideways.

To the OP, why the hell was the patient being intubated? I'm assuming since she was in a c-collar that there was a good chance she was backboarded also? I'd sit her up (if mechanism is GLF and not fell from building) or at least tilt the bed while maintaining spine precautions to get her head up and try BiPap if her mental status is decent. Again if we're not talking about high mechanism trauma (and a morbidly obese person is especially unlikely to sustain significant intra-thoracic trauma from a GLF), then controlling BP and starting dialysis will likely fix the patient's pumonary issue. 86% is a low O2 sat, but isn't by itself an indication for intubation if she's mentating well and in no apparent distress.

 

[FDNewbie]

Friend this statement is not really accurate at all.

How so?

Very rarely in the OR we go down the can't ventilate/can't intubate scenario. If all else fails for an elective case, you do wake the patient up. This has never happened to me in my short career. You don't necessarily cancel the case though. I know of instances where the patient has woken up and the operation has proceeded after an awake fiberoptic intubation.

But that's my point. You took the time to make a pre-op assessment, went down an algorithm, and when things didn't go well, you had the OPTION to wake up the patient, as well as to even consider an awake intubation (which has the underlying assumption or pre-condition that it's semi-elective, ie the patient is STILL breathing and not in a position of impending or actual respiratory failure). When I get a guy who's hypoxic and on his last breath, I can't go down the American Society of Anesthesiologists Difficult Airway Algorithm. I can't consider an awake intubation, because my patient needs an emergent airway NOW. And I can't do "the case" under MAC. And while an LMA may be a rescue device, it certainly isn't something I should start with, because I'm not intubating to get through a short-term case; I'm intubating because I need a definitive airway for respiratory compromise/failure or definitive airway protection. That's all I mean. Some options on the pathway aren't really applicable nor are they appropriate for the ED environment, although they are entirely appropriate in the OR under controlled & predetermined & pre-planned circumstances.

We see a good amount of cases where waking up is not an option and we must proceed as needed down the algorithm without turning back. Trauma patients do not get woken up for a do-over or cancellation. Neither do the cases that come up to the OR for airway control (angioedema, pending airway obstruction from tumor, patient in respiratory distress).

And that's kinda my argument. A "good number" vs. that's pretty much almost all of what I deal with. RARELY am I intubating purely for airway protection (hemorrhagic stroke, significant head trauma). Mostly it's for severe respiratory stress with immediately impending failure.

Most of our cases are elective and we have the luxury of advance preparation that is not possible in the ED. This is not always the case though.

So that's pretty much all I was saying. Hence why you can't apply all the Anesthesia rules & methods in the ED. While some may very well be applicable (the basics never change), there are other constraints & limitations that make other rules & methods inapplicable & unrealistic in the ED environment.

I'm not really sure why you wouldn't have the ability to go through a difficult airway algorithm in the ED. The modalities may change slightly depending on user proficiency, but the stops along the way stay relatively constant.

Because as mentioned above, the algorithm calls for things like LMAs, doing cases under MAC, and awake intubations. That's not what we're dealing with in the ED. Here's the algorithm I'm referring to:

If your ED doesn't have a Bougie, or a Glidescope, or LMAs then either bring them with you on a shift (easier for the 1st and 3rd option) or get the hospital to pony up. As ED docs, most of us expect to be successful with our first modality (either DL or Glidescope). And the data shows we usually are. That's not an excuse for not having a rigorously thought out plan for what to do when things go sideways.

I think maybe I wasn't clear in my earlier response. You're referring to an ED doc's backup/rescue devices (and what some of us may call OUR ED difficult intubation algorithm). My earlier comment was in response to the Anesthesiologist's comment, so I was speaking in terms of HIS Difficult Intubation Algorithm (the flowshart above), which again, is VERY different than our stepwise approach, and has options not applicable to the ED at all. My simple point was, you can't take stuff like that and just say "well you shoulda gone down that pathway in the ED" cuz it's not MADE for the ED, and much of it isn't an option & doesn't apply.

And I agree with you 100% that we should have bougies, LMAs, and some version of video-assisted intubation (I'm a big fan of the C-MAC because it has all the features of the Glidescope but is a MUCH better educational tool as well).

Hopefully that clears up what I was trying to say.

 

[Rendar5]

Anaesthesia does have to deal with non-elective cases and gets called for last breath airways in plenty of hospitals (and this was not a last gasp airway scenario).

No need to jump down their throat in the initial post, just take what you can from this and point out how that in the majority of hospitals, there is no anaesthesiologist there in time and their approach cannot work in those cases.


What the first anaesthesiologist described was a perfectly adequate approach to this patient if this were to be a tertiary care center, with anaesthesia and ENT there at the moment, or if the EP was well-versed in awake intubation. (There was one resident in my program last year who I am sure would've gone for that approach with success). It is not an approach I would have taken, and I prefer to go down the ED Difficult Airway Algorithm.

 

[Arcan57]

I was thinking of the ED difficult airway algorithm as well.

 

[Old_Mil]

Miller 4 vs. Glidescope +/- bougie.

 

[Groove]

Miller 4 vs. Glidescope +/- bougie.

Miller 4?! Intubate many Elk in your ED?

 

[Painter1]

Miller 4 vs. Glidescope +/- bougie.

never used bougie with glidescope. is using bougie with glidescope straightforward? what about using it with regular et tube stylet.

i find the rigid stylet for the glidescope annoying at times (e.g., i can't advance past a point with more of a comfort zone).

 

[Arcan57]

Miller 4?! Intubate many Elk in your ED?

In residency we had a psych patient that liked to perch open safety pins on her valecula. She got to wear she could take a Mil 4 with 2 of Versed and not even cough. Trained a whole generation of ENT docs.

 

[WilcoWorld]

never used bougie with glidescope. is using bougie with glidescope straightforward? what about using it with regular et tube stylet.

i find the rigid stylet for the glidescope annoying at times (e.g., i can't advance past a point with more of a comfort zone).

I've used a bougie with a CMAC with great success. As for the rigid stylet, I prefer to shape a conventional stylet to the desired shape and use that. It puts the ETT where I want it to go (as the rigid stylet does), but (unlike the rigid) allows me to advance the ETT easily once I'm there.

 

[Arch Guillotti]

How so?

I thought I was pretty clear. What part didn't you understand?