Emergency Airway Management – for non anesthesiologists covering ICU

Your goal is to save a life: ventilate and increase oxygenation. Intubation is the last resort to achieve this goal.

Check with your local ICU team/admin leadership for specifics optimal method of oxygenation before intubation

The information provided is based on available literature and placed here only for education to help docs deployed to cover the ICU and emergency department during the COVID-19 pandemic. 

Protect yourself – mask, face shield, double glove, disposable gown. 

NO AMBU BAG MASK VENTILATION – increases the risk of transmission of COVID-19 virus to staff. 

A. Start with a nasal cannula (NC) 5-6 liters to keep SPO2 >95% if less than <94% try non-rebreather mask at 15 l 

B. If SPO2 <94% after above measures then pre-oxygenate for 5 min with NRM at 15 l of oxygen before intubation

C. Use ketamine 1.5 mg/kg in normovolemic patient or 0.5mg/kg to 1 mg/kg in hypovolemic patient if ready to intubate.

QUICK TIPS TO MANAGE AIRWAYS

1. Oxygenation in better in semi-upright position – 30 to 45 degrees

2. Extend neck – unless neck/head trauma 

3. Jaw thrust – lifts epiglottis – opened mouth – remove dentures if easy to remove

4. Nasopharyngeal airway – size small than the opening of nose, from nostrils to mandible – length. Typical size 6-7 mm size

– insert in the patient who has low GCS helps to keep the tongue away from obstructing the airways and improve pre-oxygenation before intubation

5. Intubation laryngoscope: check battery and light. Choice of the blade: straight blade to lift epiglottis or curved blade inserted above epiglottis laryngoscopes. Straight allowed to raise the tongue in bigger person better

6. Insert and curve stilet into ET to your liking make sure it is secured at the proximal end

7. Check and inflate/deflate balloon if adequate time

8. Leave syringe attached to ET

9. Use a minimal amount of lubrication around the cuff

10. MacGill forceps use for removal of the foreign body like older patients with the tooth being knockout or dislodged dentures.

11. Keep laryngoscope in the left hand and ET in the right hand or have an assistant hold ETt, suction the saliva and secretions to clear the field.

12. Insert blade toward patient right mount and sweep the blade toward the middle to move the tongue away

13. Lift the handle along with it long axis allows to lift the tongue and better exposure

14. ET tube: insert from the right side of the mouth to better visualize the cord

15. Keep an eye on the cords all the time

16. Once ET inserted – removed laryngoscope following the curve of the base of the tongue

17. Inflate the balloon check for seal

Crushing blood pressure with intubation

1. sedatives – relax patient and decrease adrenaline discharge

2. positive pressure ventilation – PPV – impairs the blood return to the heart

3. Ketamine has less adverse effects on cardiovascular status

Difficult intubation 

1. Bouge – helps with the insertion of flex bouge upright – then insert ET over the bouge

2. Glide scope – laryngoscope with a video camera at the end, requires rigid stylet to insert ET

3. Fiberoptic intubation: place mouth guard (pink) in the center

a. attach oxygen into the suction port

b. insert ET into the pink mouth guard and then insert the fiberoptic scope, small movements to find the trachea

4. Emergent cricothyroidotomy

a. open surgical technique v. Seldinger: needle – wire – dilator choice depends on time and place. If using Seldinger: fill the syringe with sterile saline or water and look for air bubbles as you aspirate. Use size 6 tube. Don’t worry about bleeding; the tube will tamponade the bleeding. Army doc rule: vertical incision with a blade no 11 then make the opening wider with the blunt end of scalpel by twisting 90 degrees. Stay on the right side of the patient if you are right-handed. 

You are saving a life, so doing more is better than doing nothing.