You may have heard that intubation in the prehospital environment is at risk of being taken out of our scope of practice.
This has to do with poor first pass success rates and infrequent opportunities to perform intubation. This would be a huge mistake. There are situations where intubation is preferred over a supraglottic airway. Think about all the scenarios where this can be true for a multitude of reasons: drowning, esophageal varices, anaphylactic shock, chemical inhalation/exposure, CO poisoning, mandibular trauma, epiglotitis, complete airway obstruction, airway burns, the list goes on. Not to mention, aspiration (especially in the sickest of patients) is associated with a high percentage of mortality. So why is it that our first pass success for intubation is crap? Initial training is to blame as well as the lack of repeated practice. To be proficient in this procedure we must improve initial laryngoscopy training, identify gaps in performance, and practice frequently. There is a better way than we were initially taught and we CAN improve our first pass success rates. There is more to mention, but perhaps another time, let's dive into the top 6 intubation pitfalls.
Pitfall #1 Failure to Plan
First things first: BREATH. Very few intubations require speed, but all require a plan. Take the time to organize roles, set up equipment, prepare the patient, and COMMUNICATE the plan to your team as well as your failed airway plan. Your first intubation attempt needs to be your best attempt; this means use a bougie, the video laryngoscope, SALAD technique, anything that will improve the likelihood of first pass success.
I know we love our classic direct laryngosopy but we need to swallow our pride on this one. When you set up equipment did your remember to set up suction? Back up airways? When we prepared the patient did we place them in the ear to sternal notch position? What if you can't ventilate the patient with a BVM due to massive regurgitation of blood/fluids or trauma? What if they are hypotensive? Which brings me to pitfall # 2....
Pitfall #2 We Fail to Resuscitate
Resuscitate before you intubate. You may have heard this before. Nothing kills your patient faster than intubating a patient that is hypotensive. Studies have shown this over and over. You feel good because you got the tube but shortly after the patient goes into cardiac arrest. S**t!
Resuscitating your patient means not losing focus on the bigger picture. It means that if their blood pressure is in the toilet then give some fluids.....if it's still in the toilet, start an epinephrine or levophed drip (medical) or blood (trauma). By all means, use your push dose pressors as a bridge to a drip. But, do all these things BEFORE you intubate!
However NOTHING is absolute in medicine! There are exceptions where you need to intervene right away....got a complete obstruction that you can't remove, then who cares what the blood pressure is, right?! Maybe you decide a surgical cricothyrotomy is best? Or maybe it is not the right time to intubate and would be better to head to the hospital? Don't feel like you have to stick with the original plan if things change, just use the I Gel or King airway.
Pitfall #3 We Fail to Optimize Oxygenation
We all know to preoxygenate our patient before intubation. What happens once we remove the NRB or stop breathing for the patient to perform intubation? The SpO2 drops during the entire attempt until we reconnect the BVM and start breathing. Well, the SpO2 has a lag time and the number you see in real time is what the SpO2 was 30-60 seconds ago. I cannot tell you how many times, before I knew any better, I watched someone intubating and the SpO2 is at 88...84....80...Okay tubes in!... This is no bueno!
Remember that whole pulse ox lag time thing, so in this case it says 80% but by the time you see this number, it's already more like 70 something. What can happen if the SpO2 drops too low? Well, the heart gets irritable increasing the likelihood of dysrhythmias. Severe hypoxia also causes brain tissue death. Once again we are increasing the likelihood of cardiac arrest and/or permanent neurological deficits!
So what do we need to fix? Well, first, we need to preoxygenate the patient for at least 3 minutes getting the SpO2 above 94% preferably 100%. What if I can only get it to 88% on high flow oxygen? Try this little trick....place an nasal cannula under the NRB/BVM and hook it up to a second oxygen source. Okay great what else can we do? Let's use some PEEP to recruit more aveoli, attach it to your BVM or use your CPAP. Boom! We got more alveolar recruitment and the patient is preoxygenated now we are starting our intubation attempt. While attempting your intubation leave the nasal cannula on the patient at 15 lpm this will provide some oxygenation and decrease how quickly the patient desaturates.
Lastly and most importantly if the SpO2 drops below 93%, stop your intubation attempt and re-oxygenate the patient. No more than three attempts and you are finito.
Check out the DSI article in the references below, it is a must read!
Pitfall #4 Our best attempt is NOT our first attempt
I alluded to this earlier on. In order to increase our first pass success, we must use our best attempt first. Let's say you are selected for a competition to win $100,000, sweet! You arrive and the person tells you "hey you can shoot the ball from half court OR.....make a layup and still win $100,000"?
You would do the layup right?! It is the same when we are intubating, don't make it harder by saving you're best attempt for your last attempt. Studies have shown using a bougie and video laryngoscope increases first pass success. Add that with proper positioning of the patient or practicing under pressure and watch your first pass success skyrocket!
Pitfall #5 Unrecognized Esophageal Intubation
Alright this one has been beaten into our heads; verify the placement of your tube. Best way is visualizing the tube go thru the cords, then we auscultate, then we verify with EtCO2 waveform capnography, and then we mark where it is at the teeth/gums. But that's not all. Our tube is often lost during movement of the patient, so plan out your movement. Then every time we move patient....you got it!....reverify placement. And reverify again and again. We know EtCO2 is the gold standard but just because you have a reading does not mean the tube is in the cords; a low reading could indicate two things: patient has gone into cardiac arrest OR the tube has partially come out. Don't forget to print out a strip with the waveform once you get to the ER room so they can't blame you for pulling out the tube.
Pitfall #6 We Lose Sight of the Clinical Picture
This has to do with some specific situations. Let's say we have a patient in DKA that we need to intubate. We know that they are breathing fast and deep to compensate for the acidosis (kussmaul breathing). After we intubate them we must keep this compensatory breathing going. Best way to do this is check the EtCO2 or respiratory rate before intubation and match those numbers after they are intubated and sedated.
What about status asthmaticus? Here we know they have a problem getting air out; if they reach the point of intubation we have to adjust our ventilations. Ventilate the asthma patient slowly, about once every 8 seconds or so, to allow more time for them to exhale.
How about a patient with signs of increased intracranial pressure? Here our goal is to not add to the problem (ICP) and create room for perfusion of the brain. Oxygen is a vasoconstrictor that we can use to our advantage in this specific situation. We need to MILDLY hyperventilate the patient and use our EtCO2 as a guide and keep it around 30-35 mmHg. This buys space in the skull and delays brain herniation.
Here is a RSI/Intubation checklist I created, feel free to use or change:
Lastly I leave you with a challenge! Create an algorithm/plan for: massive airway regurgitation (drowned airway) and failed airway.
As always thank you for reading and I hope you find this information useful! See the references below for information on: why hypotension kills, why hypoxia kills, why acidosis kills, what are the predictable risk factors of post-intubation cardiac arrest, and more.
References:
Helman, A. H. (2018, May 1). Airway Pitfalls – Live from EMU 2018. Emergency Medicine Cases. https://emergencymedicinecases.com/airway-pitfalls-emu/
Weingart, S. D., & Levitan, R. M. (2012). Preoxygenation and Prevention of Desaturation During Emergency Airway Management. Annals of Emergency Medicine, 59(3), 165-175.e1. https://doi.org/10.1016/j.annemergmed.2011.10.002
EMCrit, A. (2020b, September 26). Preoxygenation, Deoxygenation and Reoxygenation during Intubation. EMCrit Project. https://emcrit.org/preoxygenation/
Weingart, F. S. M. D. (2016, May 15). Podcast 173 – LaMW – Oxygenation Kills Part I. EMCrit Project. https://emcrit.org/emcrit/lamw-oxygenation-kills/
Verkest, M. (2021, January 5). Episode 38 – Pediatric Intubation: Are Children Just Small Adults? FlightBridgeED. https://flightbridgeed.com/index.php/emslighthouseproject-podcast/13-ems-lighthouse-project-podcast/694-episode-38
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