I gave this lecture at SMACC 2014. It combines many former podcasts so they are now directed here (Podcast 4 & 18)

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 attempt an intubation on a difficult airway 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 & PRETREAT GAG

If you can give it early 10-15 min before topicalizing, it will be most effective.

• Glycopyrrolate: 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!
• Adminster Odansetron 4mg IV to blunt the gag-reflex

TOPICALIZE

• 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. In Canada, they have 5% paste
• Spray the epiglottis and the top of the cords with a Mucosal Atomizer Device (MAD). The patient will cough during this spraying, wear eye/face protection. I usually spray between 3-6 mls above the cords
• Alternatively, use the EZ Atomizer to topicalize everything but through the cords
• Spray into the trachea (through the cords) with 4% lidocaine (3 cc). 10% lidocaine would be wonderful to spray down the cords (not available in USA)
• 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. Push slowly.
• Remifentanil is supposedly wonderful, I've never had it to play with
• If you have neither of these 2 mg of midazolam will do just fine.

The Rest

• Preoxygenate with NRB and Nasal Cannula or CPAP + NC
• Optimally position (ear to sternal notch) with the head tilted all the way back
• Restrain both arms with soft restraints to prevent the “grabbies”. Explain why, don't do this in the UK.
• Switch to just nasal cannula @ 15lpm. You may need to place back the CPAP mask between attempts
• INTUBATE with Fiberoptic laryngoscope and bougie
• If the patient coughs or is uncomfortable after placing the bougie through the cords, push more med from the ketofol or ketamine syringe.
• Thread  the tube over the bougie with the laryngoscope still in the mouth
• Confirm tube placement
• Push a slug of sedation

Thanks to my former residents

Thanks to Raghu and Xun for risking their singing careers and to Jimmy & Anita for technical support.

Additional Reading/Viewing

• This is the best article I have found on Airway Topicalization for Awake Intubation
• VL vs. FO for awake [cite source='pubmed']25764403[/cite]
• Self FOI

Additional New Information

More on EMCrit

• Emergency Awake Topicalized (EAT) Intubation – An Awake Intubation Update(Opens in a new browser tab)
• EMCrit 247 – The Dissociated Awake Intubation with my buddy, Ketamine(Opens in a new browser tab)
• EMCrit 194 – Definitive Emergent Awake Intubation with George Kovacs(Opens in a new browser tab)

Additional Resources

• Author
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Scott Weingart, MD FCCM

Editor-in-Chief, at EMCrit.org

An ED Intensivist from NY.
Professor
Nassau University Medical Center
No conflicts of interest (coi).

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