April 26, 2021

In emergency medicine, the standard of care is to place an advanced airway for ventilatory or oxygenation failure, impending airway compromise, or inability to protect the airway. A patient with significant cognitive impairment may have depressed gag and/or cough reflexes, putting them at risk for aspiration. The evaluation of a patient’s risk for aspiration can be highly subjective. One common adage states: “If the GCS is less than 8, then intubate”, offering a seemingly simple and more objective standard to guide airway management. Using the Glasgow Coma Scale (GCS) score of 8 or below to evaluate the need for intubation is promoted by the ATLS course and the East Association for the Surgery of Trauma (EAST) practice management guidelines.[1][2] This practice is also commonly applied to patients with non-traumatic causes of obtundation. However, the evidence behind this practice is not clear, prompting many to re-examine this oft-repeated lesson.

January 9, 2020

Background: Rapid sequence intubation (RSI) is the most widely utilized approach for patients requiring emergency tracheal intubation.  RSI typically requires the use of a induction agent followed by the use of a neuromuscular blocking agent (NMBA) to improve the overall intubation conditions and therefore improve first-attempt intubation success rate. Historically, succinylcholine has been the preferred NMBA, due to its fast onset (45 – 60 seconds) and fast offset (6 – 8 minutes of paralysis). Recent studies, however, show that rocuronium is an effective agent (similar timing of onset for ideal intubating conditions) as well.  When used at a dose of 1.2mg/kg, rocuronium has a similar onset time to succinylcholine of about 1 minute. Additionally, succinylcholine has several contraindications (see bottom of the post) while rocuronium has no contraindications (except for hypersensitivity) which has increased the debate about the paralytic agent of choice for RSI.

January 6, 2020

Background: Although the standard positioning for intubation is supine in the sniffing position, there has been recent literature in the past decade that elevating the head of the bed to 25 to 30 degrees may be a preferable setup for direct laryngoscopy due to improved laryngeal view and reduced airway complications. These studies have been conducted in multiple settings and patient populations including the prehospital setting, the emergency department, and the operating room (for elective cases). Additionally, video-assisted laryngoscopy has been a relatively recent innovation in airway management: the first video laryngoscope produced commercially became available in 2001. Similarly, this technology has been studied in multiple settings including in the emergency department and in the operating room. Both head-elevated direct laryngoscopy and video-assisted laryngoscopy have been studied with a variety of outcomes including first-pass success rate, time to intubation, and mortality rates. However, despite video-assisted laryngoscopy becoming increasingly ubiquitous, its limitations include a high cost and the possibility of components becoming damaged. Both of these innovations in intubation—video-assisted laryngoscopy and elevating the head of the bed—remain debated within the field of emergency medicine.

November 11, 2019

Background: Peri-intubation cardiovascular collapse (shock, cardiac arrest or death) is an all too common complication of airway management in critically ill patients seen in up to 25% of patients (Jaber 2010, Umobong 2018). The causes for collapse are numerous and include acidosis, pulmonary hypertension, vasodilation, iatrogenic (medications used in intubation) and hypovolemia. Administration of fluids may help to mitigate the hemodynamic effects of intubation, particularly if decreased venous return is an issue, but this approach is untested.

November 4, 2019

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).