A discussion of the practice of ED Critical Care

***Had to take the actual video down pending IRB Approval. If you’d like to see it, send me an email***

Awake intubation can save your butt.

It requires forethought and humility–you must be able to say to yourself, “I am not sure I will be able to successfully intubate this patient.” However, the payoff for this thought process is enormous. You can try an intubation in the ED with very few downsides. If you get it, you look like a star, if you don’t you have not made the situation worse.

Two of my critical care resident specialists, Raghu Seethala and Xun Zhong, volunteered to intubate each other awake. The purpose of this was to let them gain experience, understand what their patients would feel during the procedure, and to prove that awake intubation can be done without complicated nerve block injections or fragile equipment, such as a bronchoscope.

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 mg 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

For more info on awake ED intubation, you can view a complete lecture here

Thanks to Raghu and Xun for risking their singing careers and to Jimmy & Anita for technical support. *
The opinions on this site and in the video represent the author’s and not the opinions or policies of the Mount Sinai School of Medicine or Elmhurst Hospital Center. It is not my intention to provide specific medical advice for any individual patient. Please confirm anything on this video with your own clinical judgment and the policies and procedures of your institution. This video is for education purposes only; it does not represent a standard of care or clinical advice.

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