The airway is one of the most critical topics in the ER. Read everything about the airway; it is not a waste of time. Even if you have to spend one year just for airway, it is worth it. You will always be confident in dealing with whatever situation that might come to you. Although reading is essential, practicing and getting experience on airway issues is essential too. So, reading along with exposing many patients is a great combination to achieve good skills.
Build your own skills by reading then summarizing your own words. As long as it is correct and safe, the way accomplishing or securing the airway may not be important in many patients.
Here are some tips in airway management at the Emergency Department (ED)
I will mention some points that might help in the management of typical scenarios at the ED. They might look random, but trust me, it is the real deal.
- Attach the patient to monitor
- Check the vitals,
- Check saturation continuously,
- Open IV lines (2x) and attach a bag of normal saline,
- If the blood pressure is low use pressure cuff on the fluid’s bag,
- If the patient maintains oxygenation don’t bag, just leave the mask on. Moreover, do not forget; bagging is not a safe procedure.
- Your equipment’s; choose your tube size depending on the patient’s size, size of the laryngoscope
- Make capnography ready
- Call the respiratory therapist, if you don’t have one, you check the ventilation machine by yourself
- Keep bougie on the side, and SUCTION! Doesn’t matter Yankuer or not anymore, as long as it takes away whatever is on your way. Don’t go too deep to avoid vomiting.
- Raise the bed highest, keep the level of the patient up to your chest or even higher, the higher the better.
- Have someone on your side in case you needed tracheal manipulation or pressure to facilitate the view.
- Never intubate before knowing the blood pressure readings.
- Never intubate with low blood pressure below 90 systolic.
- Resuscitate then intubate.
- Neutral hemodynamic resuscitation (some studies tried the use of paralytic agent alone, with local anesthetic on the glottis, the same idea as awake intubation, in case of hemodynamic instability to avoid the use of induction agents that might decrease hemodynamics). The risk of using multiple doses of an induction agent can cause hemodynamic instability.
- However, if there is no contraindication, you can think of using ketamine to help boost the blood pressure.
- Double the dose of your medication if the patient has low cardiac output. As with low cardiac output, the medication won’t reach fast; it might take longer than 4 min. There is no harm in increasing paralytic agents ONLY IF THE AIRWAY IS NOT DIFFICULT. Induction agents can be used as boluses also, but again be careful if the patient is unstable as it might worsen the condition.
Here is a great video summarizing hemodynamic issues in airway management
- Use direct laryngoscopy first, use the old school equipment to keep your skills fresh, but keep the video laryngoscope ready on the side. Some experts recommends using video laryngoscope blade for direct laryngoscope and if you need, just look to the screen.
- Still failed multiple trials with the laryngoscope? Consider difficult airway. One of the recommendations is to “leave the tube in the esophagus and insert another tube; the other opening is definitely the trachea.” By the way, there are tools to understand the difficulty of the airway, so know and use it.
- Rapid Sequence Intubation (RSI) and Delayed RSI: Delayed RSI used mainly in the ICU, and many authors hate this term. However, there is no harm if the patient is maintaining oxygenation, you can give a sedative and look before proceeding to RSI. Just don’t call this approach “RSI.”
- Rocuronium or Succinylcholine; both will paralyze the patient; it is not about which one is better; it depends on the type of airway you are dealing with. If it is a difficult airway, you do not want to use rocuronium and end up bagging the patient for one hour. Using a short-acting agent is a smart move.
- However, if it is easy, use it as it would help in paralyzing the patient for an hour, but doesn’t mean the patient is fine, do not forget analgesia/sedation!
- The tube is in, yay! Good for you, but your work is not done yet. All of us been through the situation where we jump into the airway, insert the tube and leave. This is not a skill lab; it is a real patient. The patient is not moving does not mean he is fine, you paralyzed him but he can still feel. Insert the tube, attach capnography, bag, auscultate, make sure of the level of the tube’s depth, order x-ray STAT then start analgesia/sedation infusion! No matter how naive you are or had a blackout, use midazolam and fentanyl! However, please learn other options too, because different patients may require different agents.
- Propofol infusion, the bright side of Propofol is its analgesic and sedative effect, although it has a high risk of causing hypotension.
- The dilemma of which medication to use, as for induction or paralyzing. No one can tell you that one medication is better than the other. Read everything about each medication, understand it, then you make your own mixture.
As long as you keep reading, and updating your knowledge, with of course practice and exposure to different type of situations, you will always know how to deal with every situation.