Rosen & Barkin's 5-Minute Emergency Medicine Consult (39 page)

Options for patients in respiratory arrest for advanced life support (ALS) providers:

• Bag–valve management (BVM) ventilation followed by definitive airway management in the ED
  
• Orotracheal intubation
  
• Esophageal–tracheal tubes
  
• LMA
  

• Maintain in-line cervical spine immobilization in trauma
  
• Oxygen, monitor, IV
  

• RSI
  
  • Simultaneous administration of sedation (induction agent) and paralysis to provide optimal conditions for emergency airway management
    
• Prepare equipment:
  
  • Suction, BVM, various sizes of ET tubes and laryngoscope blades, stylets, medications, and backup devices.
    
• Preoxygenation:
  
  • 100% FIO
    ₂
    for 3 min
    
• Pretreatment:
  
  • Prevents physiologic sequelae of intubation
    
  • Performed 3 min prior to paralytic
    
  • Defasciculating dose of nondepolarizing agent
    
  • Fentanyl and lidocaine may minimize ICP rise and hemodynamic response to intubation in head-injured patients
    
  • Lidocaine and albuterol in reactive airway disease
    
• Paralysis with induction:
  
  • Administration of induction agent (e.g., etomidate, thiopental, midazolam, ketamine)
    
  • Rapidly followed by administration of paralytic agent (e.g., succinylcholine, rocuronium)
    
    • Succinylcholine is relatively contraindicated with anticipated difficult oral intubation, open globe injury, organophosphate poisoning, burns >3 days old, denervation syndromes, myopathies, and suspected hyperkalemia
      
    • Nondepolarizing agents (e.g., rocuronium) can be used as an alternative to succinylcholine
      
• Positioning:
  
  • Head extension, with midline cervical stabilization if trauma patient
    
  • Cricoid pressure (Sellick maneuver) is controversial and optional
    
• Placement of tube:
  
  • After muscle tone is lost (45–60 sec after succinylcholine)
    
  • Use a stylet with the ET tube
    
  • Place tube through vocal cords
    
  • Inflate cuff
    
  • Begin ventilation
    
  • Confirm correct ET tube placement
    
• Postintubation:
  
  • Benzodiazepines, opiates, or propofol used for continued sedation
    
  • Vecuronium may be used for continued paralysis
    

• Estimation of ET tube size: 4 + age/4
  
• Uncuffed ET tubes may be used in patients <8 yr old
  
• Straight Miller blade is preferred in patients <3 yr old
  
• Cricothyrotomy contraindicated in patients <12 yr old; PTV is preferred
  
• Use atropine as pretreatment to reduce secretions and attenuate vagal effect
  
• A defasciculating neuromuscular blocking agent not necessary for children <5 yr old
  

• Atracurium: 0.4–0.5 mg/kg IV
  
• Atropine: 0.02 mg/kg IV
  
• Diazepam: 2–10 mg (peds: 0.2–0.3 mg/kg) IV
  
• Etomidate: 0.3 mg/kg IV
  
• Fentanyl: 3 μg/kg IV
  
• Ketamine: 1–2 mg/kg IV or 4–7 mg/kg IM
  
• Lidocaine: 1.5 mg/kg IV
  
• Midazolam: 1–5 mg IV (0.07–0.30 mg/kg for induction)
  
• Propofol: 2–2.5 mg/kg IV
  
• Pancuronium: 0.01 mg/kg IV (defasciculating dose); 0.1 mg/kg IV (paralyzing dose)
  
• Rocuronium: 1 mg/kg IV
  
• Succinylcholine: 1.5 mg/kg (peds: 2 mg/kg) IV; 2.5 mg/kg IM/SC
  
• Thiopental: 3 mg/kg IV
  
• Vecuronium: 0.01 mg/kg IV (defasciculating dose); 0.1 mg/kg IV (paralyzing dose)
  

FOLLOW-UP

Almost all intubated patients should be admitted to an ICU.

Rarely, certain ED patients who have been intubated for airway protection or to facilitate diagnostic workup may be extubated in the ED after a period of observation and then discharged.

Respect the airway. Failure to intubate and ventilate is a life-threatening condition:

• Assess each patient for the possibility of difficult intubation.
  
• Prepare and familiarize yourself with all needed equipment and medications (including contraindications and side effects).
  
• ALWAYS formulate your backup plan in the case of a crash airway or failed standard orotracheal intubation before beginning the procedure.
  

• Murphy MF. Airway management. In: Wolfson AB, Hendey G, Ling L, et al., eds.
  Harwood-Nuss’ Clinical Practice of Emergency Medicine
  . 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2010.
  
• Reardon RF, Mason PE, Clinton JE. Basic airway management and decision-making. In: Roberts JR, Hedges JR, eds.
  Clinical Procedures in Emergency Medicine
  . 5th ed. Philadelphia, PA: Saunders Elsevier, 2010.
  
• Walls RM. Airway. In: Marx JA, Hockberger RS, Walls RM, et al., eds.
  Rosen’s Emergency Medicine: Concepts and Clinical Practice
  . 7th ed. Philadelphia, PA: Mosby Elsevier; 2010.
  

See Also (Topic, Algorithm, Electronic Media Element)

Rapid Sequence Intubation

CODES

• 96.01 Insertion of nasopharyngeal airway
  
• 96.02 Insertion of oropharyngeal airway
  
• 96.05 Other intubation of respiratory tract
  

BASICS

• Alcohol is the most commonly abused recreational agent among emergency department patients
  
• Alcohol is frequently associated with traumatic injuries
  

• Alcohol intoxication:
  
  • Directly depresses CNS function
    
  • Blood alcohol levels drop by 15–40 mg/dL/hr depending on individual variables and chronicity of alcohol use
    
• Alcohol withdrawal:
  
  • Occurs in chronic alcohol abusers after partial or complete alcohol abstinence
    
  • May occur despite a serum alcohol level >100 mg/dL (e.g., “intoxicated”)
    
  • Primarily due to loss of chronic CNS inhibition:
    
    • Profound CNS excitation
      
    • Increased catecholamine release and adrenergic tone
      

DIAGNOSIS

• CNS effects occur on a spectrum:
  
  • Relaxation
    
  • Euphoria
    
  • Sedation
    
  • Memory loss
    
  • Impaired judgment
    
  • Ataxia
    
  • Slurred speech
    
  • Obtundation/coma
    
• May also cause GI upset
  

• Early or minor withdrawal:
  
  • <8 hr after last drink:
    
    • Symptoms of a hangover
      
    • Headache
      
    • Nausea/vomiting
      
  • 12 hr after last drink:
    
    • Mild tremors/anxiety
      
    • Anorexia, nausea, vomiting
      
    • Weakness
      
    • Myalgias
      
    • Vivid dreams/nightmares
      
  • 12–36 hr after last drink:
    
    • Irritability/agitation
      
    • Tachycardia/HTN
      
    • Tremors in hands and tongue
      
  • 24–48 hr after last drink: Alcoholic hallucinosis:
    
    • Visual hallucinations most common (bug crawling)
      
    • Auditory hallucinations (buzz, clicks)
      
    • Present in minor and major withdrawal
      
  • Alcoholic withdrawal seizures:
    
    • 8–12 hr after last drink
      
    • Brief, spontaneously abating tonic–clonic activity
      
    • Precedes delirium tremens (DTs)
      
• Late alcohol withdrawal or major withdrawal:
  
  • 48 hr after last drink
    
  • DTs:
    
    • Clouded consciousness and delirium
      
    • Confusion/disorientation
      
    • Agitation/combativeness
      
    • Tachycardia/HTN
      
    • Hyperpyrexia
      
    • Diaphoresis