Awake Intubation

From Emcrit. Performing an awake intubation.

Here is the procedure for ED Awake Intubation–EMCrit Style:

DRY THEM OUT (Do All)

If you can give it early 10-15 min before topicalizing, it will be most effective.

  • Glycopyrolate: 0.2 mg IVP (No central effects – does not cross BBB. You can use atropine, but more side effects are possible)
  • Suction and then pad mouth dry with gauze – you want the mouth very dry!

TOPICALIZE (Do All)

  • 5 cc of 4% lidocaine nebulized @ 5 liters per min
  • Gargle with viscous lidocaine (4% best, 2% ok). Place a blob (~3 cc) on a tongue depressor, put it in the back of the throat and have the patient gargle and then spit
  • Spray the epiglottis, cords, and trachea with 4% lidocaine (3 cc) in a Mucosal Atomizer Device (MAD). The patient will cough during this spraying, wear eye/face protection
  • Have another syringe loaded with 4% lidocaine to spray with during the procedure

Note: the systemic and pulmonary absorption from this method is quite low. The only place to watch out is spraying the trachea. I would not spray more than 2-3 cc down the ol’ windpipe.

SEDATE (Choose one!)

  • Ketamine and propofol in the same syringe makes Ketofol. The classic mix is 50 mg of ketamine to make 5 cc and 50 mcg of propofol to make 5 cc. Put these both in a 10 cc syringe and shake. Depending on the patient’s hemodynamics, I sometimes will use more ketamine (75% instead of 50%). Give 1-2 cc every minute until you have the patient relaxed, but still breathing and arousable.
  • Ketamine alone also works just fine. Start with 20 mg and give 10 mg every minute or so.
  • If you have it, Dexmedetomidine also works very well as long as your patient is not bradycardic.
  • If you have neither of these 2 mg of midazolam will do just fine.
  • Preoxygenate with NRB
  • Optimally position (ear to sternal notch) with the head tilted all the way back
  • Restrain both arms with soft restraints to prevent the “grabbies”
  • Switch to nasal cannula
  • INTUBATE with Fiberoptic laryngoscope and bougie
  • If the patient coughs or is uncomfortable after placing the bougie through the cords, push the remainder of the ketofol syringe.
  • Thread  the tube over the bougie with the laryngoscope still in the mouth
  • Confirm tube placement

That’s all for this week

 

 

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