[PCL] Owning the Airway (when you don't own the airway)

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How do you set up the room for a patient to be intubated if you aren't credentialed for airway management? What do you do while you're waiting for someone to come in and tube the patient?

Step 1: Decide the patient needs to be intubated

  • General indications:
    • Patient should be intubated when you're thinking about intubating (shoutout to Marino).
      • Intubate AHEAD of the curve to prevent physiologically difficult airway
    • Refractory hypoxemia/hypercapnia, clinical course, increased WOB, severe encephalopathy
    • Algorithms: ABCDEF, etc

Step 2: Prepare the Room

  • Not necessarily hard to do but you need help. Recruit your colleagues! Nurse, RT, etc
  • Optimize IV access

Step 3: Preoxygenate

  • Not just NRB! Most aren't true 100% NRB
  • Best bets: NRB + NC (both turned to "flush rate"), HFNC + NRB, pure BVM, BiPAP
    • NRB doesn't have complete seal so room air is going to entrain in mask, reducing FiO2
  • GOAL: denitrogenation of the lungs to ensure more time to intubate, not necessarily SaO2 100%

Step 4: Plan, Develop Shared Mental Model

  • Verbalize/brief the room about the patient - get whole room on same mental model to move like well oiled machine
    • "This is emergent" vs "this is non-emergent", expectations
  • Difficult airway predictors: physiologically (i.e. PHTN) or anatomically
  • What do anticipate can go wrong? (I.e. worsening shock, etc)

Step 5: Call Airway Manager

  • Use "James Bond" moment - "Do you have preference on medications you want to draw up to be prepared on your arrival?", know patients last potassium for contraindications to sux
  • Run through formal checklist or "STOPMAID" - a mental checklist to know you have everything is ready

Suction

Is suction working on wall? Prevent airway disaster

Tools

VL or DL? ETT? Difficult airway box (scalpel, bougie)? LMA? OPA/NPA? PEEP valve?

Oxygen

Oxygenating and denitrogenating appropriately

Postion

Sniffing position at head of bed

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Monitors

Blood pressure cycling every two min (esp w/o a line), SaO2 probe on other arm

Assistant

Roles are clear and defined, you know who will be helping intubator

IV Access

Should have been optimized; at least 2+ good PIVs, IO at bedside if needed

Drugs

If you communicated with airway provider, should be drawn up and ready to go

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Step 6: Verbalize plans A, B, C to room

"There is no such thing as an emergent intubation; only emergent oxygenation followed by slow controlled intubation" - Scott Weingart

Step 7: Post Intubation Management

  • Illusion of success: highly recommend staying in room as long as possible (5-10 min) to look for post intubation hypotension, desaturating, PTX, evidence of R main stem, etc
  • Orders
    • Vent order set
    • First ventilator settings
    • P/A/D strategy
    • CXR, ABG (1 hour post-intubation)