Awake Intubation Guidelines

Link to Article

Link to PDF

Ahmad, I. , El‐Boghdadly, K. , Bhagrath, R. , Hodzovic, I. , McNarry, A. F., Mir, F. , O'Sullivan, E. P., Patel, A. , Stacey, M. and Vaughan, D. (2019), Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults. Anaesthesia. doi:10.1111/anae.14904

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Ketamine for Rapid and Delayed Sequence Intubation

Alternatives to Rapid Sequence Intubation: Contemporary Airway Management with Ketamine

What are your experiences with ketamine for intubations?

I am really glad that I stumbled onto this article that was shared by @the_resuscitationist and @medicotactico.

When you're dealing with airways and medications that have can concerning adverse effects, you really shouldn't trust me on anything and should read the article yourself. Link in bio. This one is also completely free! Also, everything I typed for this post didn't fit in the space allowed by IG, so if you want to finish reading all my thoughts, you have no choice but to head over to my website. It is what it is and this article got me fired up!

For my physicians/NP/CRNA/PA colleagues who manage airways: How do you utilize ketamine for these situations?

For my ICU and ED nurses who push this medication: what have been your experiences with it?

The first thing the authors state is something those of us in the ICU or ED’s already know, establishing an airway is the riskiest commonly performed procedure in acute care. I do not proceed with pushing meds unless I have all my ducks in a row and I have plan A, B, and C easily accessible.

Here’s what happens with ketamine versus other agents that are commonly used: the patient becomes dissociated, they get that glassy look in their eyes, basically disconnected, but the brain stem reflexes stay intact... well... most of the time. You need to be prepared for it to hit the fan at any time. The patient should continue to breath spontaneously. The patients hemodynamics should also be augmented. Again, the key word is “should”. I’ve seen patients become apneic as well as hypotensive but more on that later. I’m just glad I’m not the only one who has seen these effects which are described in the literature. Nurses, don’t push ketamine like a bolus. Push it over 30-60 seconds. I know there’s a ton of adrenaline rushing in those rooms and you're used to pushing meds.

Here’s a strategy I learned from this article. Go ahead and push the ketamine when the patient is agitated and thrashing to allow for preoxygenation. The patient should chill out and when they cease thrashing, one can move forward with a preoxygenation strategy. They even explained certain cases where patients were provided with ketamine for this reason and then didn’t even need intubation.

What’s the dose? 1-2mg/kg of IDEAL body weight.

One of the things that I have noticed clinically when administering ketamine to establish and airway is the clenched jaw. Here, the authors recommend using midazolam, propofol, or even a sub-induction dose of etomidate. Just be aware that these agents bring their own baggage to the party.

Here's what the authors say about the hypotension related to ketamine. First, you need to know whether you think the patient is catecholamine depleted. In other words, they are in shock and they are running out of steam. Those patients should be resuscitated to the best of your ability and you may have to cut the dose in half. Again, read the article for yourself.

Lastly, the authors discuss using ketamine for sedation but it should be kept at dissociative doses or else your patient is going to have some no-so-good experiences. You may need to add some propofol at that point.

For respect of the authors, I will stop there. Read it for yourself. Again, it's free! Thank youuuuu!

- EJ





Link to Article

Link to FREE PDF

Merelman, A., Perlmutter, M., & Strayer, R. (2019). Alternatives to Rapid Sequence Intubation: Contemporary Airway Management with Ketamine. Western Journal of Emergency Medicine, 20(3), 466–471.

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Airway pressure release ventilation (APRV) during acute hypoxemic respiratory failure

Link to Article

link to full FREE PDF

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

How to position your patient prior to intubation: ramped vs. sniffing

We still don’t know what’s the best way to position our patients to intubate them; ramped position (torso and head elevated) which has had some theoretical OR benefits vs. sniffing position (torso supine, neck flexed forward, and head extended). Patients did worse with the ramped position. An important takeaway is listed below. I do recommend that you add the Cormack-Lehane Grade views to your airway notes. This, combined with what medications you used, what size glidescope or blade you used definitely helps with future intubations. You should learn to look for prior intubation notes to prepare for difficult airways. All it takes is one bad one and your confidence will be shattered. Don’t let it happen to you. A hat tip to the investigators. 

A Multicenter, Randomized Trial of Ramped Position vs Sniffing Position During Endotracheal Intubation of Critically Ill Adults

Semler, Matthew W.Janz, David R. et al.

http://journal.chestnet.org/article/S0012-3692(17)30881-4/fulltext

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Pre-intubation Checklist

This was essentially a negative trial but I do feel the checklist they used is very helpful for house-staff; especially those who take call without direct supervision (as I did just a few short years ago). A hat tip to the investigators. Article linked below.

A multicenter, randomized trial of a checklist for endotracheal intubation of critically ill adults. Janz DR1, Semler MW2, Joffe AM3, Casey JD2, Lentz RJ2, deBoisblanc BP4, Khan YA4, Santanilla JI5, Bentov I3, Rice TW2; Check-UP Investigators; Pragmatic Critical Care Research Group.
Chest. 2017 Sep 13. pii: S0012-3692(17)32685-5. doi: 10.1016/j.chest.2017.08.1163.
http://journal.chestnet.org/article/S0012-3692(17)32685-5/pdf

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.