Pearls for Intubation1. It takes a team to get it done.
2. The only thing rapid is the act of pushing drugs; nothing else is rapid.
3. Plan, plan, plan.
Step 1: Plan
It’s not just the tube.This step heavily relies on nursing!
- Identify what each team member’s role will be1
- Determine why the patient needs to be intubated
- What do you think could go wrong, and what will you do if it does?
- What’s the backup plan if the intubation fails?
- What’s the backup plan for the first backup plan?
Step 2: Prepare
No rushing!There is no emergency in a pandemic.
- Get your medications for before and after intubation 2.
- Gather PPE.
- Assemble equipment for intubation.
- Provide an opportunity for the patient and family to communicate.
Step 3: Position
Please, no mess.Ensure your clinical area is organized and clean.
- Position the patient for the procedure2.
- Are the team members in the right position?
- De-clutter the room of garbage, chairs, etc.
Step 4: Preoxygenate
This stage should not be rushed.Take your time.
- Give the patient the most oxygen you can2.
- You can use a bag-valve-mask, non-rebreather, anything that can deliver lots of oxygen.
Step 5: Give the Medications
The only rapid part of RSI.Everything is methodical and systematic.
- COMMUNICATE which medications to give in what order, speed and dose 2.
- Push the medications in this order:
- You can push the medicine over 10 seconds – this is the only rapid part of intubation.
Step 6: Placement with Proof
Wave capnography is supreme.In the midst of COVID-19, logistics of acquiring a chest x-ray are complicated.
- Once the endotracheal tube is in, confirm its placement with waveform capnography 2.
- If you don’t have waveform capnography, you can use a capnograph.
- if you don’t have a capnograph, you can auscultate for air entry.
- A chest x-ray does not confirm tube placement.
- A chest x-ray confirms the depth of the endotracheal tube only.
Step 7: Post-Intubation Care
Nurses stay.Everyone leaves. This is where nurses are needed the most.
- Confirm what sedation level and pain scores to achieve (see fundamentals of critical care) 2.
- Confirm medications to use to sedate the patient.
- Keep the head of bed at 30 degrees unless contraindicated.
- Consider physical wrist restraints.
- Suction the mouth.
*Please note the team pushed the paralytic (rocuronium) before the induction agent (ketamine). It is more common to see the induction agent before the paralytic. That being said, there are special circumstances where you may see rocuronium given before ketamine. Josh Farkas has a post on it rocuronium before ketamine for RSI here.
With the exception of the drug sequencing, the intubation procedure is standard.
A COVID-19 Specific Intubation Sim
A Video of an Intubation
- Higgs, A. et al. British Journal of Anaesthesia, Guidelines for the management of tracheal intubation in critically ill adults. Volume 120, Issue 2, 323 – 352
- Braude, Darren MD, EMT-P The Ten Ps of Rapid Sequence Intubation, Emergency Medicine News: January 2007 – Volume 29 – Issue 1 – p 8,12 doi: 10.1097/01.EEM.0000264634.15897.25