Rebellion21: Extubation in the ED via Sara Gray, MD

In this 15-minute presentation from Rebellion in EM 2021, Dr. Sara Gray discusses on when (and how) to consider extubating in your ED. As length of stay in the ED increases it is becoming more common to have patients who are ready to be extubated, while still in your ED!

Sara Gray, MD
Emergency Medicine/Critical Care
Associate Professor at the University of Toronto
St. Michael’s Hospital
Twitter: @EmICUcanada

Presentation Objectives:

1. Review when and how to extubate that ED patient who no longer need their tube
2. Refresh your skill set to ensure you are prepared for this procedure

Extubation in the ED:

• Who
  • Anatomic and physiologic simple intubation
  • Indication for intubation fully resolved (post-intoxication, post procedure, post seizure, DNR, etc…)
• When
  • Sedation/paralysis worn off
  • Able to follow commands (i.e. lift head off bed)
  • Hemodynamically stable
  • C-spine cleared
  • Cuff leak present (i.e. airway not swollen)
  • Spontaneous breathing trial (SBT) – PEEP ≤5 + PSV ≤5 for 30min
• How
  • Pre-oxygenate patient
  • Have intubation gear set up just in case
  • Suction ETT out
  • Remove devices securing tube
  • Coach the patient – Take a deep breath in, and hold it
  • Deflate the ETT cuff
  • Pull the ETT out
  • Suction mouth out
  • Place patient on O2
  • Monitor patient for 1 – 2hrs
    • 3 possibilities
      • Patient does great – Disposition
      • Patient needs some assistance – NIV
      • Patient struggling – Re-intubate

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)