intubation sequence

Tiesha Boo harvey@mcs.net
Tue, 16 May 2000 18:23:53 -0500


>
> I would strongly suspect that in most institutions the "specialty" person
> with the most experience with a "difficult" airway and intubation is the
> anesthesiologist.

I don't necessarily disagree with this observation but it's only part of the
story.

E.g., I have never seen an anesthesiologist perform a cricothyrotomy.  There
are people, albeit rarely, who cannot be intubated by any other means. On
the other hand crics are a part of the airway repertoire of ER physicians.

Anesthesiogists for all of their skill are accustomed to performing elective
fasted intubations and sometimes appear reluctant to perform RSI in other
situations.  As an example my collegue was seeing a pregnant patient near
term with severe pulmonary edema. Because he anticipated a difficult
intubation he asked for anesthesia assistance.  The anesthesiologist
insisted on performing the intubaiton via a fiberoptic scope.  As he turned
away to get his equipement the patient deteriorated and was intubated
uneventfully by the ER doc. I can think of other situations, as well, where
I or my collegues have been unable to perform an exceedingly difficult
intubation that was subsequently performed by anesthesia. If you have
"smart" anesthiologists at your hospital they will appreciate having
experienced ER docs who can perform the great bulk of their own intubations
without assistance. This shouldn't be allowed to become an issue of ego
gratification or turf wars.

Since Dr. Mattox did not actually address any substantive issues raised by
the original poster I'll give you my own opinion about them:

>>>1. I vaguely remember reading somewhere that two attempts at intubation
are
the maximum that should be attempted... is that true?<<<<

Technically (for epidemiological purposes) a failed intubation is considered
to be 3 consequetive failures. In the past one had to guess as to status of
the patient's oxygenation and thus empirical rules (such as limiting an
intubation attempt to the time that the intubator could hold their breath)
were devised. With the advent of pulse oximetry these rules have become
archaic. You should always know precisely what the patient's oxygenation
status is and should have a dificult airway algorithm (such as ASA
guidelines) as a backup.

>>>>2. If you have a choice of intubation aids, what would you choose, a
schroeder stylet, combitube, lighted wand, fibreoptics etc... (in an
emergency setting)?<<<

For a failed orotracheal intubation I would likely go to LMA as the
preferred backup option pending the availability of more experienced
personel or the performance of a surgical airway. Combitube is not a good
option in the in-hospital setting. Fiberoptics actually take quite a bit of
time to perform and may not be a good choice, e.g., where airway bleeding is
present.

>>>3. What is the place of a blind digital intubation compared to these
other
techniques? <<<<

An underutilzed technique. Thus has also been done in the field where the
patient's position simply precludes a conventional approach. We should all
probably get comfortable using it. I would only do it with the patient
paralyzed or arrested. A dental appliance that precludes the patient closing
the jaws (should the paralytic wear off) can be used.

>>>>4. What is the general approach to difficult intubations in the
emergency
setting? Should one just not tube the patient and use a bag or is there
something more definite?<<<

For starters you can look at the following airway algorithms:


   AIRWAY MANAGEMENT IN TRAUMA PATIENTS
   Thierbach AR - Anesthesiol Clin North Am - 1999 Mar; 17(1); 63-81


   MANAGEMENT STRATEGIES FOR THE DIFFICULT PEDIATRIC AIRWAY
   Wheeler M - Anesthesiol Clin North Am - 1998 Dec; 16(4); 743-761


   PATHOPHYSIOLOGY, EVALUATION, AND TREATMENT OF THE DIFFICULT AIRWAY
   Wilson WC - Anesthesiol Clin North Am - 1998 Mar; 16(1); 29-75


kiesha (but you can call me 'k')

"'Little Shop of Horrors' was NOT a documentary."