Tom Kehrl and I talk practical tips and tricks when it comes to emergency airway management. By no means comprehensive, we go through the finer points of intubation we found between two residencies, two fellowships, and supervising resident intubations. check out all the links in the show notes.
Power of NIV- will review separately, but increasingly more and more conditions are being found to be amenable to NIV (asthma, pneumonia)
ABG vs. VBG? pH and bicarbonate correlate; pCO2 looser; pO2 little correlation
- Want a summary? http://emrespodcast.tumblr.com/post/24702687156/abg-or-vbg
- pH correlates pretty well
- pCO2: If you want an accurate number, probably need ABG, but if high (>40) on VBG, then it’s high. Treat their clinical appearance.
- Really ABG just needed if looking for paO2
Dosing of meds
- Know your doses of meds, but also know what the size and mg in your med vials. Don’t get cute! Nothing will get you hated by a nurse faster than asking for 127.5 mg of succinylcholine
- Remember, you can’t overparalyze
- Ketamine literature showing it doesn’t increase IOP, ICP; bronchodilation, transient increase in BP, HR, CO
- Roc experience
- Dose it appropriately: studies have shown that if giving 1.2-1.6 mg/kg of rocuronium, intubating conditions are the same as with succinylcholine
- Avoid the potassium effect of succinylcholine
- DON’T FORGET THE POST INTUBATION SEDATION PACKAGE. Roc is longer acting, and I have seen people forget the sedation because they are not getting asked to sedate the patient bucking the vent.
Selection of Blade
- Mac 4 instead of 3: You can make a 4 a 3, but you can’t make a 3 a 4.
- Check your blade: Make sure you have a good connection and the light works. Don’t just turn it on: push on the top of the blade to see if it flickers when you are simulating the pressure you will get with intubation.
- Practice on nondifficult airway: Don’t let your first bougie be on a difficult airway!
- Rotation of tube clockwise vs. counterclockwise (either is probably fine)
- Keep laryngoscope in position after bougie is in while advancing ET tube to avoid getting stuck on soft tissue
- Preload tube onto the bougie and place the bougie/tube in the cheek/mouth
- Same as bougie, practice
- The factory recommended airway pressures are potentially too high. Try to keep it below 40 mmHg.
- Use of tongue blade to move soft tissue out of the way. Try to perform a good jaw thrust. If you do not get the tongue out of the way, you will not be successful.
- Use lube
- Straight to cuff
- Just say no to the banana and the hockey stick. Don’t try to place a curved object into a straight tube
Lube on the cuff
- Yes, evidence is weak but there.
- Low cost, potential benefit
- Theoretically plugs up channels, prevents microaspiration
- Open bottom of tube package and put small amount of surgilube on the cuff.
- Under head, lifting
- Pay attention, its on you!
- Scott Weingart: “Dominate the vent!”
Other airway resources
- PHARM Airway Course: http://prehospitalmed.com/category/airway/
- EMCRIT Podcast 70: http://emcrit.org/podcasts/rich-levitan-airway-lecture/
- Levitan Airway Course: http://jeffline.jefferson.edu/jeffcme/airway/
- Weingart/Levitan Article: http://www.ncbi.nlm.nih.gov/pubmed/22050948
Listen to the Podcast: