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