Background: Despite decades of experience with endotracheal intubation, we continue to find approaches to improving the process of how we intubate. In this talk at Rebellion in EM 2019, Rob J. Bryant, MD gave a 14 minute 12 second talk on 3 things that have changed the way he intubates (Back Up Head Elevated - BUHE, Bougie 1st Intubation, & Team Management).
Background: Rapid sequence intubation (RSI) involves the use of an induction agent followed by a neuromuscular blocking (NMB) agent to obtain optimal intubating conditions. Administration of a NMB results in apnea which, in turn, can lead to oxygen desaturation. Oxygen desaturation during rapid sequence intubation may lead to serious adverse events including dysrhythmias, hypotension, and cardiac arrest. Preoxygenation helps extend the duration of safe apnea and has 2 major goals:
Attempt to achieve an O2 saturation of 100%
Maximize oxygen storage in the lungs by denitrogenation of the residual capacity of the lungs (Approximately 95% of oxygen reservoir)
Preoxygenation is assessed in the ED but usually through pulse oximetry which is inadequate. In the operating room, anesthesiolgists use gas analyzers to quantify and optimize preoxygenation with ETO2. In critically ill patients, preoxygenation should be performed to achieve an ETO2 ≥85% based on the response to the 4th National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society ....Read More
Background: Working in the emergency department means frequently performing painful procedures on patients, often we turn to procedural sedation to make these procedures more tolerable for patients, families and clinicians alike. Ketamine is often used for this purpose, particularly in pediatrics, however, many clinicians are reluctant to use this agent due to concerns for recovery agitation or the dreaded “emergence phenomenon.” Clinicians often turn to the co-administration of various agents, including benzodiazepines and antipsychotics, to blunt this effect. The definition of recovery agitation and the means by which it is measured are inconsistent in the previous literature, leading to a dearth of evidence as to whether the practice of co-administration of medications is effective in reducing recovery agitation....Read More
You are working an ED shift with an experienced EM resident. As the resident prepares to intubate a 100kg patient with pneumonia you suggest that the head of the bed be elevated to aid in first pass success and avoidance of peri-intubation hypoxia. The resident thanks you for your kind suggestion and states ‘I just read an article in Annals of EM suggesting there was no benefit to non-supine position in ED patients.’ This is news to you. You give the resident the benefit of the doubt and ask them to send you a copy of their evidence.
Background: Predicting a challenging airway is important to assist in the most optimal approach to airway management during RSI. Two such tools include the Mallampati and LEMON scores and were derived in the pre-operative setting. Major limitations of these scores include the requirement of patients to be awake and cooperative and they don’t incorporate physiologic factors into them. The HEAVEN criteria is a recently developed tool thought to be more relevant and feasible for emergency airway assessment. Each letter of HEAVEN stands for the difficult airway characteristic:
Hypoxemia - ≤93% at the time of initial laryngoscopy
Extremes of size – Pediatric patient ≤8 years of age or clinical obesity
Anatomic challenge – any structural abnormality that is anticipated to limit laryngoscopic view
Vomit/blood/fluid – Clinically significant fluid noted in the pharynx or hypopharynx prior to laryngoscopy
Exsanguination – Suspected anemia raising concerns about limiting safe apnea times
Neck mobility issues – Limited cervical range of motion