Perhaps the most important of all topics in emergency medicine. As one of my attendings said during residency, “As long as they are breathing and have a pulse, we are okay”. Below is a quick review of RSI, most common medications, equipment and procedures, and whatever else. Read at your own leisure.
Managing an airway is a highly mentally tasking engagement which is very time dependent and requires frequent task switching. This is exactly the situation when we are prone to make small mistakes that can have detrimental consequences. One way to avoid such mistakes is to make mental and or written check lists. Approaching each situation in the methodical fashion that we are taught helps us lighten our mental load from tasks that are important but are at the same time routine, and allows us to use our mental capacity for critical analysis of each situation. In other words, when we have a checklist of the tasks that we know we will have to perform, it helps us focus on looking at the patient critically and assessing the medical situation.
Airway
RSI
prep
suction, etco2, tele, pulse ox, team (respiratory, nursing, pharmacy, post intubation sedation)
sedation
etomidate 0.3mg/kg (20-30mg)
propofol 1-2mg/kg (70-140mg)
ketamine 1mg/kg (70mg)
paralytics
succinylcholine 1.5mg/kg (100mg)
rocuronium 1-1.5mg/kg (70-100mg)
Options
Depending on the patient’s reason for intubation, your comfort level with the procedure, and acuity of the scenario, you will tend to gravitate toward the method of securing a patient’s airway that you are most confident with. Your first pass success is dependent on the comfort level that you have with the method of intubation that you choose. The following are the options that we typically have, their pros and cons.
Video Laryngoscopy
Nowadays this is the most commonly used method of intubation. Most commonly used by you = greatest first pass success.
Typically a GlideScope is used with either a Mac or
Can be difficult to use with bloody airways as the camera will get obscured.
Direct Laryngoscopy
Choose Mac vs Miller blade. Often first method in pediatric intubations. More difficult technique than video if you have not had adequate practice.
Cricothyrotomy
Once you pick up the scalpel to perform a cricothyrotomy, there is no going back. This is the last option for securing a patient’s airway if all else has failed. Perhaps this thought of a cricorhyrotomy being the last thing that stands between a patient’s life and death, makes us hesitant to timely proceed with this procedure. However many will argue that after 3 attempts at intubation with other methods, cricothyrotomy must be proceeded with in a timely fashion.
Steps:
Vertical incision
Finger dissection to feel cricothyroid membrane
Horizontal incision of cricothyroid membrane
Palpate incision/hole with finger, and advance bougie into hole
Advance 6.0mm ETT over bougie
fiberoptic intubation / direct look
Fiberoptic intubation is helpful in scenarios such as angioedema and inhalation injury. Great to practice fiberoptic scope maneuvering during your ICU rotations, perform as many bronchs as possible. The benefit of an awake look/fiberoptic look is to have the patient protect his or her airway as you assess the difficulty or need of intubation with a fiberoptic scope. In the case of angioedema, you give yourself the benefit of the patient still breathing on their own as you use the fiberoptic scope. Below is a list of things to consider for your successful fiberoptic intubation. Remember if this fails, cricothyrotomy will be indicated.
Prep
Consent/emergent, tell the patient what will happen and that they can end up getting intubated if the airway looks swollen and you are doing an awake look, get all the equipment, team, back ups. Preoxygenate with NRB. Have RSI meds drawn up and ready.
Anesthetize the airway
Oral: Use 4% atomized lidocaine, Gargle-> uvula-> vocal cords.
Nasal: Afrin spray into both nares -> anesthetize with 4% atomized lidocaine, gargle, uvula, vocal cords. Dilate nasal passage with viscous lidocaine and nasal trumpet. Load your tube on the fiberoptic scope. If anticipating pt will need intubation, advance ETT via nare to approximately oral pharynx.
ETT
Decide if you will be doing an oro- or nasotracheal intubation. Make sure your ETT is long enough if you are doing a nasotacheal intubation. Smaller caliber ET tubes are as a consequence shorter, which is important to consider.
Meds
-zofran 4mg (give prior to anesthetizing airway with lidocaine)
-ketamine 50mg (give when ready for intubation/awake look, some patient’s may need more ketamine)
-versed 2mg (give as needed for additional sedation)
Fiberoptic scope
Practice ahead of time handling the scope that is available in your department. Make sure you have suction on the scope or prepared at bedside if your scope does not have suction.
Steps: Nasal
angioedema, Ludwig’s angina
Prep/team/meds/back up
Zofran, anesthetize w/ lidocaine, nasal trumpet
Load ETT
Ketamine, versed
Look
Intubate (6-7mm ETT)
Confirm
Williams airway
Consider using if will perform orotracheal intubation or look. May be difficult or impossible if dealing with angioedema.
Steps: Oral
inhalation injury evaluation
Prep/team/meds/back up
Zofran, anesthetize w/ lidocaine
Load ETT
Ketamine, versed (if doing awake look in stable patient, sedation often not required with cooperative patient and adequate topical anesthesia)
Look
Intubate (7-8mm ETT)
Confirm
push dose pressors
Choices are epinephrine or phenylephrine. Be familiar with what your pharmacy offers as premixed push dose pressors. Consider use in emergent intubation scenarios with hypotension where resuscitation before intubation is not an option.
Epinephrine: 5-20 mcg per dose, q 2-5 minutes
Phenylephrine: 50-200 mcg per dose, q 2-5 minutes
consider complications
sedatives
ketamine - laryngospasm
propofol - hypotension, anaphylaxis, bradycardia
etomidate - cortisol depression, lowers seizure threshold
succinylcholine
hyperkalemia in neuromuscular disease, ESRD, crush injury, post burn >5 days, stroke, malignant hyperthermia.
reversal
Sugammadex - reversal for non-depolarizing neuromuscular blockers such as rocuronium
Dantrolene - treat malignant hyperthermia
Ventilator settings
Think about the clinical picture of your patient. Do they have healthy lungs, ARDS, or obstruction (COPD, asthma). In each case you want to protect the patient’s lungs and be aware of differences in ventilator settings that are unique to each scenario.
Mode
volume assist/ control - can control tidal volume (lung protective), and minute ventilation. Need to be careful and monitor PIP and plateau pressures.
Tv
6-8 cc/kg (ideal body weight) Goal of 6cc/kg in ARDS.
8 cc/kg in COPD/Asthma
RR
16-20 RR, adjust based on patient’s RR prior to intubation.
Lower RR (8-12) in COPD/Asthma to allow for increased I:E ratio (goal 1:4)
PEEP/ FiO2
PEEP 5, adjust based on ARDSnet protocol for ARDS
FiO2 100%, then decrease with goal SpO2 of 88-95%.
I:E ratio, Plateau pressure
1:2, 1:4 in Asthma/COPD
Plateau pressure goal <30 cm H20. To decrease plateau pressure, you will need to lower tidal volume.
Goals
Lower tidal volume ventilation has been shown to be lung protective.
In asthma/COPD patients, goal is to increase I:E ratio by decreasing RR. Monitor for airtrapping in obstructive patients.
Pediatric ETT sizes
(age/4) + 4 = uncuffed
subtract 0.5 for cuffed
(16 + age) / 4 = uncuffed
subtract 0.5 for cuffed
(if you notice the formulas are exactly the same except one is multiplied by 4)
Size by age (cuffed mm)
New born - 3 mm
1 yo - 3.5
2-3 yo - 4
4-5 yo - 4.5
6-7 yo - 5
8-9 yo - 5.5
10-11 yo - 6
12-13 yo 6.5
14-15 yo 7
16 - adult 7.5