Category: Resuscitation

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Verbalize the out loud prior to performing rapid sequence intubation.

The Bougie

• Ideal for situations when you’re view is suboptimal
• Advance it through the cords and into the trachea BEFORE the endotracheal tube. It will stay in place and guide the tube into position (this is called a Seldinger technique).

Video Laryngoscopy (Glidescope)

• Laryngoscope with a camera at the tip which displays on a screen at bedside
• Ideal for situations when both view and direct access to the cords is suboptimal (c-collar, poor mallampati). Some physicians use this as their primary technique.
• Use it like a camera that you advance into position so you can see the cords. Maneuver the endotracheal tube by watching indirectly on the screen.

Flexible Endoscopy

• It is a flexible stylet that you can control and has a camera at the tip.
• Advances through the cords like a bougie and the (preloaded) endotracheal tube advances over it.
• Can intubate through both the nose or mouth with this

LMA (laryngeal mask airway)

• Placed blindly and sits above the cords, forming a seal.
• Not a “definitive” airway, but can oxygenate and ventilate the patient when in a difficult situation.

Cricothyrotomy

• Immediately perform this step in “can’t intubate can’t oxygenate” situations
• The 3-step EMCrit method is best in my opinion (see link below)
  • “Scalpel, Finger, Bougie”

Additional Reading

• Overview of the bougie with videos (LITFL)
• The 3-step cricothyrotomy (EMCrit)

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The most important thing to do when preparing for RSI is to PREOXYGENATE the patient.

Step 1: Choose Your Equipment

• Miller or Mac blade?
  • Miller blade is straight (like the ‘L’ in miller)
    • Frequently used in kids
  • Mac blade is curved (like the ‘c’ in mac)
    • (Generally, this is the best choice to use on your clerkship and most common in the ED)
• Tube Size?
  • 7.5 cuffed tube for a small adult
  • 8.0 cuffed tube for a big adult

Step 2: Choose your Meds

• You need both a sedative and a paralytic to perform RSI
• Paralytic options are succinylcholine or rocuronium
  • Succinylcholine is best if you need something short acting
    • For example, when frequent neurologic checks are required
  • Rocuronium is best because it’s easy to remember (1mg/kg)
    • “Rocuronium Rocks”
• Sedative options include ketamine, propofol, and midazolam.
  • My favorite is ETOMIDATE.
    • It is hemodynamically neutral.
    • Dosing is 0.3mg/kg

Step 3: Prepare Your Equipment

• Suction
• Bag Valve Mask
• Backup airway (ex. LMA)
• Cardiac monitor
• Capnography for tube placement

Step 4: DO IT

• Push the sedative
• Push the paralytic
• Put the blade in your LEFT hand
• Open mouth with right hand
• Slowly advance (holding top of blade against tongue) until you see cords
  • The cords will be hiding under the white, cartilaginous, tongue-like epiglottis

NOTE: It’s OK if you don’t get it. It happens and it won’t make you look bad if your form was otherwise great.

Step 5: Advance the Tube and then CLOSING STATEMENT

• Generally, you want depth to equal 3x the size of the tube
• Closing statement
  • “Please attach capnography to confirm tube placement”
  • “We will need to get an X-ray, foley, OG tube and start the patient on propofol (or versed)”

CONGRATULATIONS!! THEY ARE INTUBATED!!

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How do you oxygenate a patient (while you are preparing for RSI) if suction, moving the tongue, and basic BVM ventilation are unsuccessful?

Pharyngeal Airways

• These tools bypass the posterior portion of the tongue to help with BVM ventilation
• Nasopharyngeal Airway (NP)
  • Measure from earlobe to tip of nose
  • TEST QUESTION: Don’t use in a patient with possible skull fracture
• Oropharyngeal Airway (OP)
  • Measure from earlobe to corner of mouth

Laryngeal Mask Airway (LMA)

• Essentially a modified BVM to place inside the mouth
• It fits OVER the larynx (cords, epiglottis, etc)

Retroglottic Airways

• “King”
• “Combitube”

Additional Reading

• Laryngeal Mask Airway (Wikipedia)
• King Airway (Wikipedia)
• Combitube (Wikipedia)

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Why is this Important?

• It is a poor stewardship of resources to continue a resuscitation when the prognosis is clearly dismal.
• Hospitals need to steward their resources to distribute equitable care between its patients

When is it Appropriate to Stop CPR on a Pulseless Patient?

• Patient shows signs of irreversible death
  • Rigor mortis
  • Decapitation
  • Rotting/decaying
• Patient has dismal prognosis (3 studies discuss this)
  • Implementation of the universal BLS termination of resuscitation rule in a rural EMS system
    • Non-EMS witnessed arrest
    • No return of spontaneous circulation prior to transport
    • Only non-shockable rhythms present
  • Early identification of patients with out-of-hospital cardiac arrest with no chance of survival and consideration for organ donation
    • Non-EM witnessed arrest
    • Non-shockable INITIAL rhythm
    • No ROSC despite 3 doses of epinepherine
• Duration of pre-hospital CPR and favorable neurologic outcomes for pediatric out-of-hospital cardiac arrests. A nationwide, population based cohort study
  • Less than 1% chance of recovery after 46 minutes of resuscitation

Additional Reading

• Jordan MR, O’keefe MF, Weiss D, Cubberley CW, Maclean CD, Wolfson DL. Implementation of the universal BLS termination of resuscitation rule in a rural EMS system. Resuscitation. 2017;118:75-81.
• Jabre P, Bougouin W, Dumas F, et al. Early Identification of Patients With Out-of-Hospital Cardiac Arrest With No Chance of Survival and Consideration for Organ Donation. Ann Intern Med. 2016;165(11):770-778.
• Goto Y, Funada A, Goto Y. Duration of Prehospital Cardiopulmonary Resuscitation and Favorable Neurological Outcomes for Pediatric Out-of-Hospital Cardiac Arrests: A Nationwide, Population-Based Cohort Study. Circulation. 2016;134(25):2046-2059.

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Step 1: Start Patient on Volume Assist-Control Ventilation

• The most basic mode of ventilation
  • Provides a FIXED VOLUME at a FIXED RATE
• If the patient over-breaths…
  • The ventilator will give another FULL breath
    • Can cause breath stacking and be uncomfortable in patients who are poorly sedated
    • This is not a problem in the ED because patients are typically deeply sedated

Step 2: Know your oxygenation and ventilation goals

• Oxygenation (getting oxygen in)
  • Try to keep O2 saturation >92%
• Ventilation (getting CO2 out)
  • Try to keep pCO2 <40

Step 3: Know the 4 Most Important Settings on a Ventilator

• FiO2
  • The concentration of oxygen
    • Room air is 21% oxygen (or 0.21 on the vent)
    • Maximum is 100% oxygen (or 1.0 on the vent)
• PEEP
  • The pressure applied during exhalation
    • Typical starting point is 5 (but can be increased significantly)
  • “Recruits” and opens alveoli
• Tidal Volume
  • The volume of air moved during each cycle of the vent
• Respiratory Rate
  • How fast the ventilator cycles/breaths for the patient

Step 4: Improving the patient’s OXYGENATION

• FiO2
  • Increases the amount of oxygen present for exchange in non-damaged alveoli
• PEEP
  • Increases the number of alveoli available to exchange oxygen

Step 5: Improving the patient’s VENTILATION

• FORMULA: Minute Ventilation (MV) = Tidal Volume (Vt) x Respiratory Rate (RR)
• Increasing either of these will improve ventilation

BONUS

• Patients with COPD/asthma
  • Have tendency to not get full breath out (“breath stacking”)
    • “Plateau pressures” will increase above 30
      • Can damage alveoli
      • Can cause pneumothorax
  • Treat by increasing the I:E ratio
    • Quick inhalation
    • Longggggggggggggg exhalation

Additional Reading

• Breathing (EM Clerkship)
• Dominating the Vent Part 1 (EMCrit)
• Dominating the Vent Part 2 (EMCrit)

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Hard, fast, unrelenting chest compressions are the core of ACLS!!!

Step 1: Check the Patient’s Pulse

• If the patient does not have a pulse, start CPR
  • Hard, fast, unrelenting compressions
    • Intubated patients
      • Continuous Compressions
    • Non-intubated adults
      • 30 compressions then 2 breaths… Repeat
    • Non-intubated pediatrics
      • 15 compressions then 2 breaths… Repeat

Step 2: Determine if the Rhythm is Shockable or Non-shockable

• Shockable rhythms
  • Ventricular Fibrillation (VF)
  • Ventricular Tachycardia (VT)
• Non-shockable rhythms
  • Pulseless electrical activity (PEA)
  • Asystole

Step 3: Start a Timer For 2 Minutes

• Do a rhythm/pulse check every 2 minutes

Step 4: Is the Patient in a Shockable Rhythm?

• Repeat/coordinate shocks with every 2-minute pulse check
• Give 1mg IV/IO epinephrine every 3-5 minutes
• Give amiodarone
  • 300mg with first dose
  • 150mg with a repeat dose

Step 5: Is the Patient in a Non-Shockable Rhythm?

• Give epinephrine every 4 minutes (every other cycle)

Quick Facts

• Shockable rhythms (VT/VF) have best prognosis
  • Frequently related to myocardial infarction
• Asystole has the worst prognosis
• PEA has mixed prognosis (depends on diagnosis)
  • Two types (wide and narrow)
    • “Wide” PEA frequently caused by metabolic abnormalities
      • Consider bicarb and calcium chloride
    • “Narrow” PEA frequently caused by shock state
      • Perform bedside ultrasound in attempt to determine cause
  • “The H’s and T’s”
    • Hypoxemia
    • Hypovolemia
    • Hydrogen Ions
    • Hyper/hypokalemia
    • Tension pneumothorax
    • Tamponade
    • Toxins
    • Thrombosis (MI/PE)

Additional Reading

• When to Stop CPR (EM Clerkship)

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Type and Rh

• What information it provides
  • Blood type (A, B, AB, O)
  • Rh status (Rh positive or negative)
• When to order
  • Pregnant patients with vaginal bleeding
    • Need if Rh negative (prevents hemolytic disease of newborn)

Type and Screen

• What information it provides
  • Blood type (A, B, AB, O)
  • Rh status (Rh positive or negative)
    • PLUS
  • Antibody status
    • Looks for all possible antibodies that may cause transfusion reaction
• When to order
  • When the patient needs/might need a blood transfusion
    • Test typically takes 30 minutes to run… ORDER EARLY!

Type and Cross

• What information it provides
  • Blood type (A, B, AB, O)
  • Rh status (Rh positive or negative)
  • Antibody status
    • PLUS
  • Specifically tests against patients blood
• This blood is then set aside and officially “matched”
• Acts as a final safety step before transfusion

Emergency Release Blood

• Universal donor is O negative
• Order if you can’t wait 30 minutes because the patient is dying

Additional Reading

• Straight Talk with an ER Doc with Scott Weingart (BBGuy Podcast)

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Tank. Clogged Pipes. Broken Pipes. Pump.

Introduction

• “Tank”
  • Hypovolemic shock
  • Hemorrhagic shock
• “Clogged Pipes”
  • Cardiac tamponade
  • Tension pneumothorax
  • Pulmonary embolism
• “Broken Pipes”
  • Septic Shock
  • Neurogenic Shock
  • Anaphylactic Shock
• “Pump”
  • Cardiogenic Shock

Step 1: Fill the Tank

• Establish an IV
  • IO line alternative in emergent situations

Step 2: Consider Clogs

• Cardiac tamponade
  • Diagnosis: Ultrasound
  • Treatment: Pericardiocentesis
• Tension pneumothorax
  • Diagnosis: Clinical/Xray/Ultrasound
  • Treatment: Needle decompression and tube thoracostomy
• Pulmonary embolism
  • Diagnosis: Clinical/CTA
  • Treatment: Thrombolytics

Step 3: Squeeze the Pipes

• Administer vasopressors
  • Most common: Norepinephrine
  • Alternatives: Epinephrine, Phenylepherine

Step 4: Analyze the Pump

• Get an EKG
  • Ischemia = Aspirin/Heparin/Cath lab
  • Dysrhythmia = Electricity

Additional Reading

• Airway Part 1 – Immediate Actions (EM Clerkship)
• Breathing (EM Clerkship)
• RUSH Exam (EMCrit)

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Hypoxemia fixed by only TWO things: FiO2 and PEEP

Step 1: Add FiO2

• If the patient is breathing…
  • Nasal cannula
  • Non-rebreather mask
• If the patient is NOT breathing…
  • Bag-valve mask

Step 2: Add PEEP

• *Cannot be completed in 60 seconds, but equipment can be requested
• If patient is breathing…
  • BiPAP
• If the patient is NOT breathing…
  • Intubation

Additional Reading

• Ventilator Basics (EM Clerkship)
• Airway Part 1 – Immediate Actions (EM Clerkship)
• Circulation (EM Clerkship)

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“Airway” does not necessarily mean “Intubation”

Introduction

• In emergency medicine we are taught “A-B-Cs”
  • These are actions that can be accomplished in first 60 seconds of patient encounter
    • Intubation takes several minutes to accomplish
    • Intubating a crashing patient might even KILL them!
  • Resuscitate THEN intubate

Step 1: Suction

• Immediately suction if patient is…
  • Altered and vomiting
  • Gurgling

Step 2: Move the Tongue

• Bedside maneuvers
  • Head tilt
  • Chin lift
  • Jaw thrust
• Adjunct equipment
  • Oropharyngeal airway
  • Nasopharyngeal airway

Additional Reading

• Airway Part 2 – BVM Adjuncts (EM Clerkship)
• Airway Part 3 – Rapid Sequence Intubation (EM Clerkship)
• Airway Part 4 – What to Do If Intubation Fails (EM Clerkship)
• Laryngoscope As A Murder Weapon – Hemodynamic Kills (EMCrit)