[PCL] Owning the Airway (when you don't own the airway)
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
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
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)
Attribution
Longing by Joakim Karud https://soundcloud.com/joakimkarud
Music promoted by Audio Library https://youtu.be/wSL0sGLTgLQ